pulpal and periapical disease

Question 1

pulpitis

Answer 1

• Most common cause of dental pain /
  toothache
• Usually caused by caries penetrating the
  dentine

Question 2

what happens when pulp necrosis is left untreated?

Answer 2

pulp necrosis
leads to the death of the pulp

Question 3

aetiology of pulpits

Answer 3

mechanical causes
thermal causes
chemical causes
bacterial causes

Question 4

mechanical causes

Answer 4

• Trauma
• Iatrogenic damage during a dental procedure
• Attrition
• Abrasion

Question 5

thermal causes

Answer 5

• Uninsulated metallic restoration
• During cavity preparation
• Polishing

Question 6

chemical causes

Answer 6

arise from erosion

Question 7

what are the usual causes of pulpitis?

Answer 7

caries penetrating the dentine
leads to inflammation of the pulp

Question 8

classification of pulpits

Answer 8

reversible pulpitis
irreversible pulpitis

Question 9

reversible pulpits: clinical features

Answer 9

• Mild to moderate inflammation of the pulp
• Cold stimuli are common triggers
• Pain is not spontaneous
• Relief occurs once the stimulus is removed

Question 10

reversible pulpitis histopathology

Answer 10

pulp hyperaemia
cellular response
formation of tertiary dentine

Question 11

pulp hyperaemia

Answer 11

– Mild to moderate
inflammatory reaction
– Vital pulp remains intact

Question 12

cellular response

Answer 12

– Specialised cells in the pulp
migrate
– Cells proliferate and
differentiate into
odontoblasts

Question 13

formation of tertiary dentine

Answer 13

– Occurs at the dentine-pulp
complex
– Acts as a protective
response to injurious
stimulus

Question 14

treatment of reversible pulpits

Answer 14

• Placement of Restoration
  – Used if a cavity is present
• Removal of Noxious Stimuli
  – Seal exposed dentine in
  cases of abrasion
• Prevention and Periodic Care

Question 15

clinical features of irreversible pulpits

Answer 15

• Paroxysms of Pain
  – Triggered by sudden temperature changes, especially heat
  – Pain persists even after the stimulus is removed
• Spontaneous Pain
  – Pain may occur without any apparent trigger
• Exacerbation of Pain
  – Bending over and lying down increases pain due to
  intrapulpal pressure changes
• Electric Pulp Vitality Test
  – Affected tooth reacts at a lower current level compared to
  normal teeth

Question 16

clinical and pathological features of irreversible pulpits

Answer 16

• Nighttime Pain
  – Patient often awake at night due to
  severe pain
• Difficulty Identifying Affected Tooth
  – Pain may be referred from maxilla to
  mandible or vice versa
  – Referred pain to ipsilateral ear or sinus
  – Pain does not cross the midline
• Increased Pulp Pressure
  – Lack of escape of inflammatory
  exudate
  – Severe inflammation of the pulp
• Compression of Pulpal Blood Vessels
  – Results in hypoxic cell injury
  – Leads to pulp necrosis

Question 17

treatment of irreversible pulpits

Answer 17

root canal therapy
extraction of affected tooth

Question 18

severe pulpits symptoms

Answer 18

• may cause dull pain
• can be relatively asymptomatic

Question 19

mild pulpits symtoms

Answer 19

may cause excruciating pain

Question 20

chronic hyperplastic pulpitis

Answer 20

• Represents an excessive, exuberant,
  proliferation of chronically inflamed dental
  pulp tissue.
• Arises due to an extensive carious exposure
  of a young pulp with subsequent
  development of granulation tissue, covered
  at times by epithelium.
• Results from long-standing, low-grade
  pulpitis.
• Most commonly involves deciduous molars
  and first permanent molar due to rich blood
  supply and large root opening in a young
  otherwise healthy patient.

Question 21

periapical inflammatory disease: pathogenesis

Answer 21

Periapical inflammatory disease: pathogenesis
* A common sequelae of an untreated or
inadequately treated irreversible pulpitis
with pulp necrosis.
* Spread of infection occurs through the
apical foramen into the periapical tissues.
* Occasionally the infection spreads via an
accessory root canal and then becomes
located on the lateral aspect of the root of
the affected tooth.
* Both microbial and host factors play a role
in determining whether the periapical
inflammation manifests as an acute
inflammatory process, known as a
periapical abscess or as a chronic
inflammatory process, known as a
periapical granuloma.

Question 22

periscopical abscess definition

Answer 22

refers to the accumulation of acute
inflammatory cells at the apex of a non-vital
tooth.

Question 23

pariapical abscess clinical features

Answer 23

the associated tooth is non-vital,
severe constant pain, extreme sensitivity to
percussion, tooth may be extruded. Headache,
fever and malaise may be present.

Question 24

periapical abscess radiographic features

Answer 24

may show widening of the
apical periodontal ligament, often no periapical
lesion visible on the radiograph because a de
novo periapical abscess is an acute process and
insufficient time has occurred for significant bone
destruction.

Question 25

periapical abscess histological features

Answer 25

Aggregation of neutrophils often intermixed with inflammatory exudates, cellular debris and bacterial colonies.

Question 27

periapcial abscess treatment

Answer 27

Drainage and elimination of the focus of infection.

Question 28

complications of a untreated periapcial abscess

Answer 28

* Spread into the medullary bone resulting in osteomyelitis. * The purulent material may drain through a fistulous tract intraorally forming a parulis (gum boil) or extraorally via a cutaneous sinus through the overlying skin. * Perforation of the cortex and diffuse spread into the overlying soft tissue resulting in a cellulitis. * The purulent material may drain into the blood stream resulting in a bacteremia - which in turn can lead to fatal consequences such as cerebral abscess, cavernous sinus thrombosis or mediastinitis.

Question 29

periapical granuloma definition

Answer 29

refers to a mass of chronically inflamed granulation tissue at the apex of a non-vital tooth.

Question 30

periapical granuloma clinical features

Answer 30

most lesions are assymptomatic

Question 31

radiographic features of periapical granuloma

Answer 31

presents as a periapical radiolucency of varying size. Affected tooth typically shows loss of the apical lamina dura.

Question 32

periapical granuloma - histological features

Answer 32

Composed of a proliferation of fibroblasts and capillaries that forms a mass of granulation tissue (hence the term granuloma). There is an accompanying dense chronic inflammatory cell infiltrate that is predominated by lymphocytes, plasma cells and foamy macrophages.

Question 33

periapical granuloma treatment

Answer 33

Root canal therapy or extraction followed by curettage of the apical soft tissue or apicectomy with retrograde root canal filling.

Question 34

possible consequences of untreated periapical granuloma

Answer 34

Periapical granulomas are not static lesions. They may undergo acute exacerbation and present as a so-called “chronic abscess” which becomes clinically symptomatic or they may progress to form periapical / radicular cysts.

Question 35

periapical abscess - acute inflammation

Answer 35

* Intense pain * Extremely tender to percussion * No radiographic changes

Question 36

periapcial granuloma - chronic inflammation

Answer 36

* Dull / no pain * Slightly tender to percussion * Periapical radiolucency