2: Systemic Pulpal & Periradicular Diagnosis

Question 1

how is subjective information gained?

Answer 1

talk to patient prior to clinical examination

Question 2

patient’s chief complaint: how should information be recorded?

Answer 2

in patient’s own words

Question 3

past medical history:

• keep history updated how often?
• what to remember about older patients?

Answer 3

• each visit to dentist

- older patients tend to have more complicated medical problems

Question 4

past medical history: conditions that require special consideration for endodontic treatment?

Answer 4

• radiation therapy of oral tissues
• disorders of immune system
• cardiac conditions
• latex allergy
• hepatitis
• bleeding disorders
• steroid replacement therapy

Question 5

history of present complaint: obtained by?

why should patients be handled with care? in what type of environment?

Answer 5

• questions and answers regarding history of present symptoms
• because of pain, apprehension and altered emotional state. environment should be friendly and compassionate

Question 6

dental history: what should be noted?

Answer 6

• why patient attended
• any recent treatment?
• when did problem begin
• what factors influence the present complaint?

Question 7

significant aspects of pain? elaborate on each

Answer 7

location: ask pt to point to the tooth, location can be difficult if inflammation has not spread to pl?

character/intensity: more intense, more disruptive to lifestyle. intense pain: recent onset, no relief from analgesics. can be caused by irreversible pulpitis, acute apical abscess. long standing pain not as intense.

origin: spontaenous or provoked. spontaenous intense pain = severe pulpal/periradicular pathology
duration: intermittent or continuous

Question 8

continuous pain:
with thermal stimulus - indicates?
with application of pressure - indicates?

Answer 8

• irreversible pulpitis

- periradicular pathology

Question 9

collection of medical and dental history, identification of signs and symptoms - what diagnosis can the clinician reach?
what else is required to collect more info to confirm diagnosis?

Answer 9

• tentative diagnosis

- will require objective examination to confirm tentative diagnosis

Question 10

objective examination: gained by? x3

Answer 10

clinical examination
special investigations
radiographs

Question 11

clinical examination: what are the extraoral and intraoral tissues? what to examine for?

Answer 11

extraoral: general appearance, facial asymmetry, swelling, TMJ, lymph nodes

intraoral:
- soft tissues: lips, oral mucosa, cheeks, tongue, palate, attached gingiva.
check for discoloration, inflammation, sinus tracts

• dentition: check discoloration, fractures, toothwear, caries, large restorations

Question 12

clinical tests: 4 different types?

Answer 12

• mirror and probe: check discoloration, caries, fracture, defective restorations, sinus/fistula
• periodontal examination
• periapical tests: TTpercussion, TTpalpation, pulp sensibility
• radiographic examination: cone beam, CT

Question 13

periodontal examination:
- differentiates between? 
probing?
- helps detect?
mobility? 
- caused by? 
- what causes it to decrease?

Answer 13

• differentiate between periodontal and pulpal pathology
• probing is a diagnostic aid to bone and soft tissue destruction. teeth suspected of perio disease should always be probed
• mobility: caused by lack of pl support, or acute infection. successful RCT can decrease mobility

Question 14

mobility:
specific causes? what kinds of origins?
other causes?

Answer 14

• LOA
• inflammation of PDL
• can be pulpal or periodontal origin
• other causes include root fracture, trauma, occlusal trauma, orthodontic tooth movement, abnormally short roots

Question 15

periradicular tests: what 3 movement to carry out?

Answer 15

• percussion
• palpation
• mobility

Question 16

what are control teeth and what is their purpose (x3)?

Answer 16

• healthy teeth that should be tested first
  3 reasons:
• patient knows what to expect
• dentist can observe patient’s response
• can then determine if stimulus is capable of evoking a response

Question 17

percussion:
determines what?
severe response: how? indicates?
mild to moderate response: indicates?

Answer 17

• percussion determines the presence of PERIRADICULAR inflammation
• severe pain is sharp, causing patient to withdraw. indicates periradicular inflammation
• mild/moderate: indicates periodontal inflammation, periodontal disease

Question 18

percussion: how to carry out?
what if there is severe subjective pain?
what must be done first?

Answer 18

• tap on incisal or occlusal surface with mirror handle, held perpendicular to crown
• then only use gentle apical pressure applied digitally
• test control teeth first

Question 19

palpation: determines what? positive response indicates? how to carry out? what must be done first?

Answer 19

• determines if inflammation has extended periapically
• indicates periradicular inflammation
• firm finger pressure applied to mucosa
• use control tooth

Question 20

pulp sensibility testing: stimulates what nerve fibres? positive response does not guarantee ___, but indicates what?

Answer 20

• stimulates sensory nerve fibres
• does not guarantee healthy pulp, only indicates presence of some nerve fibres carrying sensory impulses
• use control teeth first

Question 21

pulp sensibility tests: what 3 types are there?

Answer 21

• thermal
• electric pulp testing
• direct dentine stimulation

Question 22

pulp sensibility testing:
normal response - occurs in?
intense, prolonged response - suggests?
no response - indicates?

Answer 22

• in vital pulp, or reversible pulpitis
• suggests irreversible pulpitis
• necrotic pulp, or false negative (immature apex, recent trauma, calcified canal)

Question 23

pulp sensibility tests: cold
what materials are used?
which teeth respond better or worse to cold tests? what is the alternative?

Answer 23

• ethyl chloride
• dichlorodifluoromethane (endofrost)
• ice sticks
• more effective on anterior teeth than posterior teeth - try electric pulp testing instead

Question 24

pulp sensibility tests: heat

what materials can be used?

Answer 24

• hot water: isolate tooth with rubber dam, syringe one tooth at a time
• gutta-percha heated on a flame
• rotation of rubber prophy cup

Question 25

electric pulp testing: technique?

Answer 25

- clean, dry, isolate tooth - place toothpaste on electrode - place tester on labial/palatal surface of tooth. avoid metal restorations - increase level of current until sensation is felt by pt

Question 26

EPT false positives: occur when? x4

Answer 26

- electrode makes contact with gingiva or large amalgam restorations - patient is anxious - liquefaction necrosis (gaseous & liquefied elements within pulp can transmit electrical charges to periapical tissues) - tooth not dry or well isolated

Question 27

EPT false negatives: occur when?

Answer 27

- patient is premedicated - inadequate contact with enamel - trauma - canal calcified - apex immature - partial necrosis

Question 28

pulp sensibility: positive response shows? negative response shows? response does not reflect the degree of ______?

Answer 28

- presence of sensory nerve fibres - pulpal necrosis - does not reflect the degree of health or disease of pulp

Question 29

pulp vitality test: | measures and assesses what? vascular supply is the most accurate marker of?

Answer 29

- measure/assess pulpal blood flow | - pulp vitality

Question 30

laser doppler flowmetry: an optical measuring method that enables? objective test of?

Answer 30

- enables the number and velocity of particles conveyed by a fluid to be measured - objective test of presence of moving RBCs within tissue

Question 31

laser doppler flowmetry: how does it work?

Answer 31

laser light transmitted to the dental pulp, by means of fibre optic probe placed against tooth surface

Question 32

laser doppler flowmetry: indications?

Answer 32

- pulp testing in children - traumatized teeth - monitoring revascularization of replanted teeth - differential diagnosis of periapical radiolucencies

Question 33

direct dentine stimulation: how to carry out? useful for? how must test be carried out?

Answer 33

cut a test cavity - useful for crowned teeth - explain test to patient, carry out preparation without anaesthesia - if tooth is vital; patient will feel a sudden, sharp pain when dentine is cut

Question 34

methods of special investigation?

Answer 34

- selective anaesthesia | - transillumination: dentine cracks, fractures

Question 35

bite test: provides? patient will feel pain upon?

Answer 35

- displacement of fragments and stretching of odontoblastic processes - patient will feel pain upon release of pressure

Question 36

radiographic examination: aids what? limitations? x3 inflammation must spread where to be visible?

Answer 36

- diagnosis - pathological changes in pulp not visible, periradicular pathology not visible in early stages, 2D - more than one view often required - inflammation must spread to involve cortical plates to be visible

Question 37

radiographic evaluation: crown | - what to look for?

Answer 37

- depth of restoration - presence of caries/recurrent caries - presence of tertiary dentine/pulp stones - size & location of pulp chamber

Question 38

radiographic evaluation: roots and periradicular area

Answer 38

- number and morphology of roots - size and shape of root canals - presence of resorption - presence of periradicular pathology - previous root canal treatment: quality, type of material, iatrogenic defects

Question 39

``` cone beam CT produces what kind of scans of the maxillo-facial skeleton? what dose of radiation? captures what? how does the x-ray work? ```

Answer 39

- 3D scans of maxillo-facial skeleton - lower dose of radiation - captures cylindrical/spherical volume of data known as field of view - pulsing x-ray beam gives up to 580 projection images, exposure of 2-5s. software then reconstructs 3D image from data

Question 40

CBCT can provide?

Answer 40

a more objective and accurate representation of osseous changes over time