Pulpal and Odontogenic Infections Flashcards by Rachel Eifert

Why is the pulp considered to be a “unique organ”?

it is enclosed by hard tissue and is non-shedding

2. inflammation is particularly damaging (there is no give)

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How does increased intrapulpal pressure result in tissue damage?

the pressure cuts off blood flow

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What is the most common cause of pulpal inflammation and necrosis?

bacterial infection

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How does infective bacteria reach the pulp? (4 ways)

Direct exposure
penetration through dentinal tubules (from caries)
direct access from traumatic fracture
from the bloodstream (unlikely)

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What is anachoresis?

bacteria traveling from the blood stream…remember its unlikely to be the cause of pulpal inflammation

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If a tooth is fractured, what is the standard of care?

Remove the surface layer and seal it up! (infection can happen very quickly after the pulp is exposed via fractures in enamel and dentin)

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If the pulp is non-vital, _____ _______ _____ in dentinal tubules is disrupted and the tooth is more vulnerable to invasion by microbes.

positive fluid pressure (innate protection)

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What are two ways in which trauma can result in tissue death?

damage the blood supply

2. sever at the apex

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True or False: Bacteria are not necessary to cause pulpal and periapical disease.

False, bacteria is necessary! the germ-free-rats proved it

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A good _____ is critical for success of pulpal therapy (pulpotomies and root canal treatment).

seal

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Most bacteria cultures from necrotic pulps are _______ and usually gram negative.

anaerobic

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Pulpal and periapical diseases have _______ strain(s) of bateria per tooth and are ________, not saccharolytic.

multiple

proteolytic

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Based on cultivation studies, which two bacterial species are associated with periapical abscesses?

Prevotella and Porphyromonas

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What is characteristic of prevotella and porphyromonas?

FOUL ODOR

P.P is stinky

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Pulpal infections have ______ micro-environments, variable ____ concentrations, and differing ______ needs as depth changes.

complex
oxygen
nutrient

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Within the canal, sccharolytic bacteria are found _____ and proteolytic bacteria are found ______.

coronally

apically

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What is pulpitis?

early stage endodontic infection where bacteria have entered the pulp

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What are the two types of pulpitis and how do they differ (pain response)?

Reversible: lowered threshold with prolonged pain response to stimuli such as COLD

Irreversible: SPONTANEOUS onset of pain is severe, sharp, or throbbing

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What stage of pulpal infection occurs just after pulpitis?

Periapical Lesions (shift the inflammatory response to surrounding tissue at apex because the blood supply is cut off to the pulp)

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True or False: Periapical lesions are often asymptomatic and only detected on radiographs.

True
because the pulp is necrotic…the inflammatory response is effective and the bacteria are confined to the periapical tissues

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Most periapical lesions are ________.

granulomas

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Periapical granulomas are ______ dominated.

macrophage

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What kind of abscess is associated with: pain that is relieved through drainage of pus?

Acute Dentoalveolar Abscess

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How does an Acute Dentoalveolar Abscess form and how does it appear?

exacerbation of a periapical lesion with a shift in bacterial species or a lowered immune response (seen as purulent bacterial infection that is confined to bone at the apex)

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Drainage of a Acute Dentoalveolar Abscess to the ____ brings relief. Whereas, drainage of the abscess to the ______ is serious due to orofacial involvement.

surface = relief | tissue space = orofacial involvement

What is the difference between pallative and definitive treatment of pulpal/periapical diseases?

``` Pallative = relieving symptoms Definitive = ridding of the cause ```

Pharmacologic treatment with analgesics or local anesthetics are examples of _____ treatment.

pallative

Extraction and root canal therapy are examples of ______ treatment.

definitive

Why are antibiotics not effective against infections that are confined to the pulp or apical periodontium?

Blood supply is cut off

What are three reasons why periapical infections persist after root canal treatment?

1. biofilm presence on the surface of the tooth apex 2. debris remained within an inaccessible region of the canal 3. foreign body fragments were displaced during instrumentation

What is an effective treatment procedure for a persistent apical lesion?

Endodontic Microsurgery (aka: Apicoectomy) - surgical access to apex via gingival flap - removal of apex tip - cleaning of apical foramen - sealed with Mineral Trioxide Aggregate (MTA)

When dental infections spread to surrounding tissues, they are called ______ infections.

odontogenic

An odontogenic infection that is localized to the alveolar area is classified as a _________ infection.

dentoalveolar

An odontogenic infection can extend to adjacent facial structures or become a _______ ______ infection.

disseminated systemic

What is the usual course of periapical infections that spread to surrounding tissues?

an initial cellulitis or tissue invasion

What is cellulitis?

infection that spreads through soft tissue via vascular channels or through direct autolysis of tissue

Tissue associated with cellulitis is _______ and ______ to palpation.

swollen and hard (indurated)

Cellulitis can progress to ________ formation, which is considered second phase.

abscess

What is clinically recognizable about second phase cellulitis (abscess)?

Pus production | -badly infected tissue can become walled off and the acute inflammatory process is stimulated with migration of PMNs

Second phase cellulitis is characterized by a ________ lesion; the first phase of cellulitis is indurated and swollen.

Fluctuant and erythematous

Is second phase cellulitis vascular or avascular?

avascular (oxygen levels are low)

Abscesses will not resolve without drainage. What are the two natural drainage routes?

1. External (intraoral or extraoral fistula) | 2. Internal (in the tissue spaces leading to potentially serious infections**)

True or False: Cellulitis and Dental Abscesses are mono-microbial.

False: polymicrobial ~4-6 species

Are there more anaerobes or aerobes in cellulitis?

anaerobes (2 or 3) to aerobes 1

Which bacterial species are most prevalent in cellulitis?

streptococci and prevotella

The presence of ______ in cellulitis usually results in more severe symptoms.

fusobacterium

Treatment of cellulitis involves: temporary management with _______, quick resolution via _________ of the source, or ______ of the tooth followed by ________ if it is well-established.

antibiotics removal of the source of infection extraction with antibiotics

If toot extraction or root canal therapy does not work for an abscess, _________ and ______ is required for resolution.

surgical incision | drainage

What are the two first line antibiotic choices for abscesses?

penicillin (most often- narrow spectrum) | clindamycin (alternate-unnecessarily broad spectrum)

What are three common bone infections?

1. Alveolar Osteitis (dry socket) 2. Osteomyelitis of the Jaw 3. Medication Induced Osteonecrosis of the Jaw (MRONJ)

What is alveolar osteitis and how does it occur?

dry sockets - delayed healing of extraction site, premature breakdown of fibrin clots that exposes bone - biofilm formation on the bone surface - painful, swollen, red, and mal-odor

How are dry sockets treated?

Systemic antibiotics do not work | -gentle debridement and medicated dressing

How does osteomyelitis of the jaw present?

radiolucent area of bone that may be surrounded by an involucrum (white line), pain, swelling, and possible pus

How do you treat osteomyelitis of the jaw?

surgical debridement | longterm antibiotic therapy

How does MRONJ present itself?

as exposed bone that does not heal with swelling, pain, redness, ulceration, and pus

What are two predisposing factors of MRONJ?

1. immunosuppressive cancer treatement | 2. high-dose IV bone antiresorptive agents (bisphosph)

True or False: MRONJ is fairly common in cancer patients and occurs in approximately 30% of cases.

False: it is rare, less than 2%

Why does MRONJ occur?

antiresorptive agents prevent osteoclasts from remodeling bones (becomes non-shedding) while the bone surface also has decreased vascularity. Biofilms form on the exposed bone surface after dental procedure.

True or False: MRONJ occurs in adults and children.

False. Not reported in children

MRONJ has mixed species bacterial and ______ biofilms.

yeast

How do you treat MRONJ?

1. Insist on a "drug holiday" from the anti-resorptive drug 2. Systemic antibiotics 3. Remove biofilm by debridement

List the diseases from least to most severe: | apical periodontitis, bone infections, abscess, acute apical abscess, cellulitis, pulpitis

``` Least to Most: Pulpitis apical periodontitis acute apical abscess cellulitis abscess bone infections ```