Pulpal and Periapical Diseases Flashcards
8 tests available to determine origin of pain
- Clinical examination - visual, explorer, trans illumination
- Electric Pulp Tester
- Cold Test - Ice / Ethyl Chloride / Endo Ice
- Hot test - Gutta percha
- Percussion/ bite “tooth sleuth”
- Palpation of the alveolus
- Cavity Test
- Imaging (radiographs, CBCT)
4 potential causes of pulpitis
- Bacterial infection (caries)
- Mechanical damage - removal of dentin too close to pulp
- Thermal injury - inadequate water-air spray
- Chemical irritation - disinfectants or toxic fluids
Define reversible pulpitis
A clinical diagnosis involving reversible inflammation of the pulp
Define symptomatic irreverible pulpitis
A clinical diagnosis indicating that the vital inflamed pulp is incapable of healing
Define aymptomatic irreversible pulpitis
A clniical diagnosis indicating that the vital inflamed pulp is incapable of healing
7 signs and symptoms of reversible pulpitis
- Sudden mild to moderate pain of short duration (subsides within seconds after removal of the stimulus)
- Different from dentinal sensitivity (ICE CREAM)
- Usually in response to cold or sweet but sometimes heat
- Does not occur spontaneously
- Not worse when lying down
- Mild increase in sensitivty to electric pulp tester
- NO increased mobiltiy or sensitivity to percussion
Treatment for reversible pulpitis
Remove the source of irritation
8 signs and symptoms of irreversible pulpitis
- Sharp severe pain to heat that continues after removal of stimulus
- Cold, heat, sweet or acidic foods cause pain
- Spontaneous pain
- Usually lasts longer than 20 min
- Worse when lying down
- May be difficult to localize, pain may be referred to other teeth
- Throbbing pressure late, heat worsens but cold may produce relief
- No pain to percussion
2 treatment options for irreversible pulpitis
- Removal of pulp (RCT)
- Extraction
Define periapical granuloma
Mass of chronically inflamed granulation tissue at apex of a non-vital tooth (usually asymptomatic). Not a true granuloma. Chronic inflammation surrounded by fibrous connective tissue
Cause of periapical granuloma
Bacteria in the root canal system liberate toxins in the apical region from a dead (non-vital) tooth. May be associated with an endodontically treated tooth if there is no apical seal
Radiographic appearance of periapical granuloma
Rarefying osteitis - focal loss of bone –> well-defined periapical radiolucency
5 treatment options for pericapical granuloma
- Eliminate offending microorganisms
- Antibiotics not usually indicated unless systemic symptoms
- RCT or retreatment of root canal
- Extraction if tooth cannot be restored
- Periapical surgery with biopsy and retrograde fill if retreatment fails or a post + core that cannot be removed are in place
4 characteristics of periapical (radicular) cyst
- Usually asymptomatic unless acutely inflamed
- Non vital tooth
- Well-defined periapical radiolucency
- Loss of lamina dura
Define periapical abscess
Accumulation of acute inflammatory cells at apex of a non-vital tooth. May be symptomatic or asymptomatic. Tooth usually sensitive to percussion
Cause of periapical abscess
May arise de-nova from non-vital tooth or from a pre-existing periapical granuloma or periapical cyst
Results of tests on tooth with periapical abscess
- Usually sensitive to percussion
- No response to cold
- No response to electric pulp tester
- No response to a test cavity (use high speed bur without LA)
Symptoms of periapical abscess
- Asymptomatic if pus can drain from site
- Headache
- Malaise
- Fever
Radiographic appearance of periapical abscess
Widening of periodontal ligament space or ill-defined radiolucency. If very early, no radiographic changes detectable
Define parulis
A sessile papule on the gingiva at the site where a draining sinus tract reaches the surface (gum boil)
Define sinus tract
A drainage pathway from a deep focus of infection to an opening on the surface
Define fistula
A drainage pathway between two epithelium lined surfaces (oro-antral fistula)
Biopsy results of parulis
Acutely inflamed granulation tissue
Management of parulis
- Treat source of infection or else would reoccur
- Gutta percha point may be used to tract the origin of a fistula
Define cellulitis
- Spread of infection into soft tissues. Usually requires hospitalization
- Acute and diffuse infection of soft tissu, usually resulting from the extension of a periapical abscess
- Diffuse spreading of purulent exudate along fascial planes that separate the muscle bundles
Evaluation of patient with cellulitis
- Always ask if patient can swallow (fluids or pills)
- Always ask if there is any difficulty breathing
- Always evaluate for any change in level of consciousness
- Evaluate fever - is patient toxic
Treatment of patient with cellulitis
- Not localized, therefore incision and drainage will not liberate pus – a small amount of bloody fluid may drain from the site
- Incision and drainage in soft tissues or through tooth (source of infection must be removed - pulpectomy or extraction)
- Antibiotics - first line = penicillin or clindamycin
- Fluid replacement / maintain patent airway
- Patient should improve in the next 12 - 24 hours - if worse, IV abx may be necessary (microbiology - culture and sensitivity)
NOTE: no treatment = potential death
Define Ludwig’s angina
Cellulitis involving fascial spaces between muscles and other structures of the posterior floor of mouth which may compromise the airway. Patient should be admitted to hospital
Potential consequence of thrombophlebitis of the cavernous sinus
Brain abscess and death
Define osteomyelitis
Inflammation involving marrow spaces and medullary bone. Most commonly caused by an extension of an untreated periapical abscess. More common in mandible vs. maxilla (more vascular)
Biopsy results of acute osteomyelitis
Necrotic (non-vital bone) associated with neutrophils.
NOTE: bacterial colonies may be present on the surface of bone. Sequestrum formation. Diagnosis requires clinical correlation. Radiogrpahic correlation and Gallium scan may be helpful
4 predisposing factors for osteomyelitis
- Bone disease (i.e. osteoporosis)
- Bone lesions (i.e. Florrid osseous dysplasia)
- Radiotherapy of bone secondary to treatment of a malignancy (osteoradionecrosis)
- Immunocompromised patient
5 types of osteomyelitis
- Acute suppurative osteomyelitis
- Chronic suppurative osteomyelitis
- Diffuse sclerosing osteomyelitis
- Condensing osteitis (focal sclerosing osteomyelitis)
- Osteomyelitis with proliferative periosititis
Clinical features of accute suppurative osteomyelitis (4)
- Pain
- Fever
- Malaise
- Paresthesia
Radiographic appearance of acute suppurative osteomyelitis
- Early lesions = few signs with conventional rx
- Advanced cases = moth-eaten bone destruction
8 symptoms and consequences of chronic suppurative osteomyelitis
- Swelling
- Pain
- SInus formation
- Purulent discharge
- Sequestrum formation
- Tooth loss
- Pathologic fracture
NOTE: May arise from acute suppurative or denovo
Define focal sclerosing osteomyelitis
Localized area of bone sclerosis associated with the apices of teeth with pulpitis or pulpal necrosis
NOTE: No radiolucent border and not separated from the apices of teeth
Describe diffuse sclerosing osteomyelitis
Pain, inflammation and increased diffuse opacity of bone
Define osteomyelitis with proliferative periostitis (Garre osteomyelitis)
Bone formation with periosteal reaction in response to inflammation
Most frequent cause of osteomyelitis with proliferative periostitis (Garre osteomyelitis)
Dental caries
Appearance of Garre osteomyelitis on occlusal films
Onion skin appearance
Treatment of osteomyelitis (4)
- Remove source of infection
- Debridement and surgical drainage
- High dose antibiotic therapy (months)
- Hyperbaric oxygen therapy (used less frequently)
Cause of alveolar osteitis (dry socket)
Premature fibrinolysis of the initial clot
6 characteristics of alveolar osteitis (dry socket)
- More frequent in mandible
- 25 - 30% of impacted 3rd molar
- 20 - 40 years of age
- Bare bone socket
- Severe pain, foul odor
- 10 - 40 days duration
Management of alveolar osteitis (dry socket)
- Obtain PA (rule out retained root fragment/foreign body)
- Remove sutures, irrigate warm saline
- Inspect socket clinically but DO NOT CURRETAGE
- Home irrigation saline or chlorhexidine
- Antiseptic dressing to pack socket? reduces symptoms but may delay healing
Define pulpal necrosis
A clinical diagnostic category indicating the death of the dental pulp. The pulp is non responsive to pulp testing
Define condensing osteitis
Diffuse radiopaque lesion representing a localized bone reaction to a low-grade inflammatory stimulus, usually seen at the apex of a tooth
Define symptomatic apical periodontitis
Inflammation, usually of the apical periodontium, producing clniical symptoms including a painful response to biting and or percussion or palpation. May be assocaited with an apical radiolucency
Define acute apical abscess
An inflammatory reaction to pulpal infection and necrosis - rapid onset, spontaneous pain, tenderness of tooth to pressure, pus formation and swelling of associated tissues
Define asymptomatic apical periodontitis
Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area, and does not produce clinical symptoms
Define chronic apical abscess
An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little discomfort or no discomfort, and the intermittent discharge of pus through an associated sinus tract
