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Endodontics > Diagnosis and management of pulpal and periapical disease > Flashcards

Diagnosis and management of pulpal and periapical disease Flashcards

1
Q

What mechanical tests are there to examine pulpal/periapical inflammation

A

Palpation
Percussion
Periodontal probing

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2
Q

Describe the palpation mechanical test for pulpal/periapical inflammation

A
  • Compare with contra-lateral side

- Negative response does not indicate the absence of inflammation

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3
Q

Describe the percussion mechanical test for pulpal/periapical inflammation

A

Positive response may be due to:

  • Infected pulp
  • Occlusal trauma
  • Sinusitis
  • Cuspal fracture
  • Periodontal disease
  • Inflammation at the apex
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4
Q

Describe the periodontal probing mechanical test for pulpal/periapical inflammation

A
  • Wide pocketing is more likely to be a periodontal problem
  • Narrow pocket is either a sign of a fractured tooth or could be where the infection from the root canal is draining like a sinus tract but through the periodontal pocket
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5
Q

What do indirect sensibility tests rely on to indicate +ve to -ve responses

A

They rely on stimulation of A-delta nerve fibres to indicate blood circulation within the pulp

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6
Q

What kinds of indirect sensibility tests are there

A

Thermal - Cold, Heat

Electrical

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7
Q

What are the differential diagnoses of a sinus tract and periodontal disease with sensibility tests

A

Periodontal = within normal limits

Endodontic sinus tract disease = no response

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8
Q

What are the differential diagnoses of a sinus tract and periodontal disease with periodontal probing

A

Periodontal = Wide pockets

Endodontic sinus tract disease = narrow tract

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9
Q

What are the differential diagnoses of a sinus tract and periodontal disease with the clinical status of the tooth

A

Periodontal = minimal caries

Endodontic sinus tract disease = evidence of caries, restoration

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10
Q

What are the differential diagnoses of a sinus tract and periodontal disease with the general periodontal condition

A

Periodontal = poor

Endodontic sinus tract = within normal limits

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11
Q

What are the examination procedures required to make an endodontic diagnosis

A
  • Medical/dental history: past/recent treatment, drugs
  • Chief complaint: how long, symptoms, duration of pain, location, onset, stimuli, relief, medications
  • Clinical exam: facial symmetry, soft tissue, periodontal status, caries, restorations
  • Clinical testing: thermal, electrical
  • Periapical tests: percussion, palpation
  • Radiographic analysis: new periodicals (at least 2), bitewing
  • Additional tests: transillumination, selective anaesthesia
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12
Q

Describe the progression of soft tissue changes with pulpal disease

A
  • Reversible pulpitis
  • Irreversible pulpitis
  • Hyperplastic pulp
  • Pulp necrosis
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13
Q

What can reversible pulpitis be caused by

A

Transient and maybe due to either dental caries, erosion, attrition, abrasion, trauma or operative procedures

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14
Q

What are the symptoms of reversible pulpitis

A
  • Pain does not linger after stimulus is removed
  • Pain is difficult to localise (pulp contains nociceptive fibres not proprioceptor fibres)
  • Teeth not tender to percussion
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15
Q

AY BAWS CAN I HABE DE NOTE PLZ

A

Although dentinal sensitivity per se is not an inflammatory process, all of the symptoms of this entity mimic those of reversible pulpitis

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16
Q

How does reversible pulpitis appear radiographically

A

Normal periradicular appearance

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17
Q

Describe the treatment of reversible pulpitis

A
  • Either cover exposed dentine
  • Remove the stimulus
  • Remove the stimulus and restoring the tooth
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18
Q

AY BAWS CAN I HABE DE NOTE PLZ

A

Antibiotics therapy is not indicated for irreversible pulpitis

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19
Q

What are the symptoms of irreversible pulpitis

A
  • Pain can develop spontaneously
  • Severe pain
  • Pain lingers after stimulus is removed
  • Response lasts from minutes to hours
  • Pain to hot liquids received by cold
  • Sometimes the pain may be accentuated by postural changes such as lying down or bending over
  • Over the counter analgesics are usually ineffective
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20
Q

Why might irreversible pulpitis be difficult to diagnose

A

As the inflammation has not yet reached the periapical tissues, which would result in no pain or discomfort to percussion

  • So dental history and thermal testing are usually used to assess pulpal status
  • When periodontal ligament is involved pain becomes localised
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21
Q

How does irreversible pulpitis present radiographically

A
  • Normal peri-radicular appearance

- In later stages, a widened periodontal ligament

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22
Q

What are the treatment options for irreversible pulpitis

A
  • Root canal treatment or extraction
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23
Q

What is hyperplastic pulp and what is it caused by

A
  • Form of an irreversible pulpitis known as a pulp polyp

- Due to proliferation of a chronically inflamed young pulp tissue

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24
Q

What are the treatment options for hyperplastic pulp

A
  • RCT

- Extraction

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25
Q

What is pulp necrosis and when does it happen

A
  • Occurs at the end of an irreversible pulpitis

- Pulp becomes non-responsive to pulp testing and is asymptomatic

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26
Q

Why might some teeth be non-responsive to pulp testing

A

Due to calcification, recent history of trauma or simply the tooth doesn’t respond

  • all testing must be comparative e.g. the patient may not respond to thermal testing on any teeth
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27
Q

What are the treatment options for pulp necrosis

A

Root Canal Treatment or Extraction

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28
Q

What hard tissue changes can occur with pulpal disease

A
  • Pulp calcification

- Resorption

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29
Q

Describe physiological secondary dentine

A
  • Formed continuously after tooth eruption and root formation
  • Deposited on the floor and ceiling of pulp chamber rather than walls
  • with time can result in occlusion of pulp chamber
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30
Q

When is tertiary dentine laid down

A

In response to environmental stimuli:

  • reactionary dentine response to mild stimuli
  • reparative dentine response to strong noxious stimuli
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31
Q

What is the link between pulp inflammation and resorption

A

Pulp inflammation occasionally caused resorption of the dentine by dentinoclast cells:

  • clinically a pink spot can be seen
  • a punched out lesion continuous with the rest of the pulp cavity can be seen
32
Q

What are the treatment options for internal dentin resorption caused by pulp inflammation

A

RCT

If resorption is too advanced then XLA

33
Q

What are the clinical features of cracked vital teeth

A
  • Sharp pain on biting or release, occasional pain from cold
  • Difficult to localise
  • Tooth slooth, staining, transillumination (diagnosis?)
  • More common in mandibular molars, especially 2nd molars
34
Q

What are the treatment options for cracked vital teeth

A

RX Ortho band/Cu band/temp crown then progress to cusps coverage restoration

35
Q

What are the clinical features of cracked non-vital teeth

A
  • Dull ache on biting
  • Teeth not tender to percussion (TTP), narrow perio pocket adjacent to fracture
  • Radiographically halo, J shaped diffuse lesion surrounding the root
36
Q

What are the treatment options for cracked non-vital teeth

A

RX

XLA/consider hemisection

37
Q

What are the clinical classifications of peri-apical disease

A
  • Acute apical periodontitis
  • Chronic apical periodontitis (+/- acute exacerbation)
  • Apical periodontitis with and abscess (chronic/acute)
  • Apical periodontitis with a sinus tract (Acute/chronic)
38
Q

What is acute apical periodontitis and what is it caused by

A

Periapical inflammation caused by:

  • Traumatic occlusion
  • Bacteria/toxins from infected/necrotic pulps
  • Overinstrumentation
  • Extrusion of irrigants or materials during RCT
39
Q

What are the clinical features of acute apical periodontitis

A
  • The tooth is tender to biting
  • Tooth sensibility tests +ve/-ve
  • Can be tender to palpation
40
Q

What does acute apical periodontitis show radiographically

A

No change or could have widening of the PDL

41
Q

What is the treatment for acute apical periodontitis

A
  • RCT

- XLA

42
Q

What is the presenting complaint (PC) of chronic apical periodontitis

A

Nil or moderate/severe pain (acute exacerbation)

43
Q

What is the common History of Presenting Complaint in patients with chronic apical periodontitis

A
  • Previous pain
  • Recent restoration in the tooth
  • RCT been carried out
44
Q

What are the diagnostic tests for chronic apical periodontitis

A

-ve to tooth sensibility tests

May be TTP (teeth not tender to percussion) and/or tender to palpation

45
Q

What are the radiographic findings for chronic apical periodontitis

A

Widening to an apical radiolucency

46
Q

What are the treatment options for chronic apical periodontitis

A
  • RCT

- XLA

47
Q

How does the trabecular bone respond to irritation radiographically

A

Shows concentric radiopaque around the root

48
Q

If a patient comes in with what symptoms do they need to go to A&E

A
  • Patient is pyrexic
  • Limited opening
  • Difficulty swallowing
  • Large swelling such as surrounding near the eye and crossing midline under the chin like for instance signs of ludwigs angina
  • Patient needs to go to A&E and be admitted to max fax for IV antibiotics and their care and management
49
Q

Give examples of things that can cause pain that mimic acute odontogenic pain

A
  • Trigeminal neuralgia, MS
  • Cancer, osteoarthritis
  • Rheumatoid arthritis
  • Facial arthromyalgia
  • Migraine
  • Tension headache
  • Bruxism
  • Allergic/bacterial sinusitis
  • SCA
  • Herpes zoster
50
Q

Where else might you see radiographic lesions that you may mistake to be of endodontic origin and how can you avoid making this mistake

A
  • Mental foramen
  • Nasopalatine foramen
  • Maxillary sinus
    Normal vitality tests and radiographs at different angles will reveal lesion is not so closely associated with the root
51
Q

Name some materials that are used to maintain pulp vitality

A
  • Calcium hydroxide

- MTA

52
Q

What is the mode of action of calcium hydroxide when used to maintain pulp vitality

A
  • Antibacterial on wound surface
  • High pH
  • low grade irritation from the coagulation necrosis produces hard tissue barrier
  • Releases growth factors from dentine matrix to signal cellular response for pulpal repair and dentine bridge formation
53
Q

What is Mineral Trioxide Aggregate (MTA) composed of

A
  • Portland cement (75%)
  • Bismuth Oxide (20%)
  • Calcium sulphate (5%)
54
Q

What does Mineral trioxide aggregate (MTA) do to help maintain pulp vitality

A
  • Antimicrobial and biocompatible
  • Releases growth factors from dentine matrix to signal cellular response for pulpal repair and dentine bridge formation
  • Good seal
55
Q

What are the treatment options for reversible pulp damage

A
  • Indirect pulp capping

- Direct pulp capping

56
Q

Describe indirect pulp capping treatment for reversible pulp damage

A

Where infected softened carious dentine removed and leave a layer of leathery type non infected dentine over the pulp:

  • Wash dry cavity
  • Calcium hydroxide (setting)/MTA placed
  • Restore and review
57
Q

Describe direct pulp capping treatment for reversible pulp damage

A

Where pulp is exposed through non-infected dentine and has no recent history of spontaneous pain:

  • Wash area with sterile water and arrest bleeding
  • Place calcium hydroxide/MTA
  • Restore with a bacteria tight seal
  • 1 year later check radiographically and also tooth sensibility tests
58
Q

Name some treatments for irreversible pulp damage

A
  • Pulp amputation

- Pulpectomy

59
Q

Describe a pulp amputation (pulpotomy)

A

Part of exposed inflamed pulp removed and preserves remaining pulp e.g. incomplete root formation is exposed.
Damaged tissue is removed using a high speed bur under cooling with sterile water/saline
Bleeding is arrested and covered with calcium hydroxide and restored and tooth monitored

60
Q

What types of pulp amputations (pulpotomy) are there and why are they different

A

Superficial damage - partial pulpotomy

Involves coronal pulp - coronal pulpotomy

61
Q

Describe a pulpectomy

A

Total pulp removal which is followed by root canal treatment

When pulp is irreversible damaged or when pulp cavity is needed for retention of a restoration

62
Q

Describe the sequence treatments that lead to endodontic treatment

A
  • Emergency treatment to deal with symptoms
  • Extraction of unsalvageable teeth
  • Dental caries stabilised
  • Preventive regime including periodontal therapy
  • Then endodontic treatment can be carried out as the patient is more stabilised
63
Q

What are the indications for RCT

A
  • Planned on teeth that are functionally and aesthetically important and have a reasonable prognosis
  • Irreversibly damaged/necrotic pulp with or without clinical and or radiological finding of apical periodontitis
  • Elective devitalisation
64
Q

What are some contraindications for RCTs

A
  • Teeth that cannot be made functional or restored with limited ferrule effect
  • Teeth with insufficient periodontal support
  • Teeth with poor prognosis like with extensive external/internal resorption, extensive vertical fractures
  • Patient is unable to tolerate rubber dam
  • Complex anatomy
  • Uncooperative patients or patients where dental procedure cannot be undertaken (limited opening/rubber dam cannot be placed)
  • Teeth of patients with poor oral condition that cannot be improved within a reasonable time
65
Q

What treatment routes need to be evaluated when considering an RCT

A

Endodontic
Restorative
Periodontal

66
Q

How do you assess the restorability prior to endodontic treatment

A

Ferrule Effect:

  • 2mm dentine axial wall height
  • Parallel axial walls
  • Metal must totally encircle tooth
  • Must be on solid tooth structure
  • Must not invade biological width
  • Need approx 5mm height of supra bony tooth structure
67
Q

What do you do if there isn’t enough tooth left

A

Consider:

  • crown lengthening
  • XLA - accept the space with denture, bridgework or dental implants
68
Q

Why are root filled teeth weaker

A
  • Loss of tooth structure
  • Wider the isthmus, loss of marginal ridge
  • Loss of roof of pulp, more cusp flexure more prone to fracture
    Altered physical properties:
  • Moisture loss, difference in collagen
    Loss of proprioception:
  • Randow and Glantz 86, load root filled teeth x2 than vital teeth
69
Q

What non vital teeth are most likely to fracture

A

Maxillary teeth more than mandibular teeth

Second molars > premolars

70
Q

How do we make sure anterior root filled teeth don’t fracture

A

They don’t necessarily need crowning and should be ok, better that teeth with posts there so fook it really

71
Q

What requirements are there for post placement

A
  • Minimum length of 4-5mm of Gutta Percha
  • No space between post and GP
    Other considerations:
  • Post length = to length of crown or 2/3 root length
  • Ideally at least an equal amount of post below and above the alveolar crest
72
Q

What is the function of posts

A

Retention - they don’t strengthen the roots

73
Q

What factors of a post will provide more retention

A

If the post is :

  • Longer
  • Parallel sided rather than tapered
  • Roughen surface
  • Threaded post more than other surface

Self threading posts should be avoided

74
Q

What kinds of posts are there

A

Direct/Indirect

Metal/Fibre

75
Q

What kinds of fibre posts are there

A
  • Composite - C-fibre, silica fibre, light transmitting posts, ribbon fibre materials
  • Ceramic (zirconium oxide)
76
Q

What is a nayyar core for root filled teeth

A

When amalgam is used to fill the root chamber i think hmmmmmm

77
Q

If marginal ridge is missing after RCT what should be done

A

On posterior teeth will need cusp coverage if the marginal ridge is missing

Endodontics (9 decks)

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