Diagnosis Flashcards
Q63 : Does orthodontic tooth movement impact the viability of the dental pulp?
According to Hamilton & Gutmann (IEJ-1999), orthodontic tooth movement can cause degenerative and/or inflammatory responses in the dental pulp of teeth with completed apical formation. The impact of the tooth movement on the pulp is focused primarily on the neurovascular system, in which the release of neuropeptides can influence both blood flow and cellular metabolism. As a result of that, calcification of the root canal space may occur and pulp testing may be affected.
The incidence and severity of these changes may be influenced by previous or ongoing insults to the dental pulp, such as trauma or caries.
In a recent systematic review by Weissheimer et al. (IEJ 2021), they showed that orthodontic movements do not induce loss of pulp vitality. The level of evidence, however, is if low to very low certainty.
Q64 : How influential is CBCT imaging in treatment decision-making?
CBCT can be very influential in treatment decision-making. It has been consistently showing that it has better capabilities than other imaging modalities in depicting the features of the periapical area (Tsai et al, JOE-2012).
**Rodriguez et al. (JOE-2017) **investigated the Influence of CBCT in Clinical Decision Making among Specialists. They found that examiners altered their treatment plan after viewing the CBCT scan in 27.3% of the cases. In high difficulty cases, the variation of the treatment plan increases to 52.9%.
In a systematic review by Aminoshariae et al (JOE - 2018), CBCT imaging was reported to have twice the odds of detecting a PAR than traditional PA radiographs in endodontic outcome studies.
Chogle et al. (JOE-2020) showed that CBCT imaging has a significant effect in determining the etiology of endodontic disease (55%) and in recommending treatment (49%)
Q65 : List potential causes of false negative responses to electric pulp testing (EPT)?
1- Restorations
2- EPT doesn’t have batteries
3- Trauma (Fulling & Andreasen, Scand J Dent Res - 1976)
4- Open apex (Johnsen et al, JDR - 1985)
5- Calcification of the root canal space (Bender, JOE - 2000)
6- Exposure to head & neck radiation (Garg et al, JOE-2015, Gupta et al, JOE - 2018)
7- Current passing through adjacent tooth** (Myers, JOE - 1998)**
8- Orthodontic movement (Burnside et al, Angle Orthodontist - 1974)
9- Primary Hyperthyroidism, due to hypercalcemia (Bender, JOE - 2000)
Q66 : Please describe the common features of odontogenic dental pain
- Has the hallmark features of inflammatory pain- sharp high intensity and/or dull aching throbbing pain
- Presence of etiological factors (caries, trauma, restorations).
- Ability to reproduce chief complaint during examination.
- Unilateral pain.
- Sensitivity to percussion, temperature.
- Pain reduction by local anesthetic administration.
Q67 : How does the Laser Doppler Flowmetry works? What are its limitations in clinical testing?
It evaluates dynamic changes in blood flow by detecting blood cell movement in a small volume of tissue. Recently, Laser Doppler has been shown to be superior to cold tests and EPT in testing the pulp vitality of traumatized teeth (Ahn et al, JOE - 2018)
Limitation
Signals obtained from human teeth do not necessarily indicate pulpal blood flow and may be confounded by signals obtained from nearby tissues. (Polat et al, Arch Oral Biol. 2004)
Q68 : How often is CBCT being used in today’s practice in the United States?
Setzer et al. (JOE-2017) investigated the acceptance, accessibility, and usage of CBCT imaging among members of the AAE in the United States by means of an online survey. They found that among the people who completed the survey (1083 participants), 80 % had access to a CBCT unit, 49% of which had CBCTs in their offices.
Q69 : What is the difference between “sensitivity” and “specificity” of clinical exams?
Sensitivity = the ability of a test to identify teeth that really are diseased
Specificity = the ability of a test to identify teeth without disease.
Q70 : How often does a tooth with irreversible pulpitis also presents with percussion or biting sensitivity?
Owatz et al (JOE 2007) showed that the Incidence of mechanical allodynia in patients with Irreversible pulpitis was around 57%
Q71: How accurate are the current AAE diagnostic term in identifying the status of the inflamed pulp (reversible or irreversible pulpitis)?
According to Ricucci et al (JOE-2014), the classification of pulp conditions as normal, reversible or irreversible pulpitis is highly accurate in the large majority of cases. The clinical diagnosis of normal pulp or reversible pulpitis matched the histologic diagnosis in 96.6%. The clinical diagnosis of irreversible pulpitis corresponded to the histologic diagnosis for this condition in 84.4%.
Q72 : What is “condensing Osteitis”? And why it develops?
It’s a radiopacity at the root apex because of a proliferative bone response to a low-grade chronic irritant.
Green et al (JOE - 2013) showed that the histologic changes of condensing osteitis consisted of the replacement of cancellous bone with compact bone. All teeth exhibiting condensing osteitis had an identifiable etiology that likely resulted in degenerative pulp disease.
Q73 : Which of the following clinical tests is the most reliable to determine the pulp vitality?
Cold test // Electric pulp test // Heat test
Petersson et al (Dent Traumatol-1999) evaluated the ability of thermal and electrical pulp tests to register pulp vitality. The cold test was the most accurate at 86%, followed by EPT at 81% and Heat at 71%.
Weisleder et al (JADA 2009) recommended the use of Cold test and EPT in conjunction for more accurate diagnostic testing.
In a recent systematic review by Mainkar & kim (JOE-2018):
* Laser Doppler flowmetry, and pulse oximetry were the most accurate pulp diagnostic methods. - – Heat testing was the least accurate diagnostic method.
* EPT was highly accurate when testing vital teeth, but demonstrated low accuracy when assessing nonvital teeth.
* Cold testing demonstrated generally high diagnostic accuracy and can be considered a primary pulp testing method.
Q74 : How does the pulse oximetry test works? And how accurate it is?
Light emitting diodes at 2 wavelengths (red, infrared) transmit light through vascular tissue, absorbed selectively by oxygenated and deoxygenated hemoglobin.
Measure the oxygen level (oxygen saturation) of the blood
Gopikrishna et al. (JOE-2007) showed that the accuracy of the pulse oximetry test was 97.5% compared to 86% for the cold test, 81% for the electrical test.
Q75 : Can analgesics taken before a dental appointment affect the endodontic diagnosis testing results?
YES
Read et al. (JOE-2014) showed that Ibuprofen intake prior to the dental appointment affected the testing values in teeth with symptomatic irreversible pulpitis & symptomatic apical periodontitis by masking the clinical symptoms in:
- Palpation: 40%
- percussion: 25%
- Cold: 25%
Q76 : What is the correlation between radiographic success and histological success?
Brynolf (Odont Revy 1967) showed that even though many radiographs appeared normal, complete histological healing after non-surgical root canal treatment occurred in only 7% of the cases.
Green et al (0000E 1997), on the other hand showed that complete histological healing after NSRCT occurred in only 74% of the cases.
Q77 : Why a periapical lesion may be clinically present but not radiographically visible on a periapical radiograph?
Lesions in cancellous bone cannot be detected using periapical radiographs (PA). They have to reach the cortical plate to start appearing on a PA. (Bender & Seltzer, JADA - 1961 & part I & Part 2) (this article was republished in 2003 in the JOE)
Although CBCT may have a better detection than PA, Tsai et al (JOE-2012) showed that even CBCT may have poor accuracy in detecting simulated lesions smaller than 0.8 mm in diameter.
