pain diagnoses

Question 1

pulpitis

signs and symptoms
treatment

Answer 1

short sharp pain (seconds)
triggered by stimuli
analgesics relieve pain
no TTP

give LA, provide temporary dressing (GIC) + definitive restoration later

Question 2

pt presents with short sharp pain, lasts a few seconds. triggered by cold drinks. analgesics relieve pain and there is no TTP. what is the diagnosis?

Answer 2

reversible pulpitis

Question 3

irreversible pulpitis

signs and symptoms
management

Answer 3

pain of long duration (hours)
dull and throbbing ache, pulsatile
spontaneous and may disturb sleep
analgesics don’t relieve pain effectively
may be worsened by heat or lying down
in later stages, cold might actually relieve symptoms
may be TTP
exaggerated or reduced response to EPT
*pain remains after removal of the stimulus

localisation difficult initially but as inflammation spreads to periapical tissues it will become more sensitive to pressure
management:
XLA or RCT
access and pulp extirpation
if pt experiences pain after goof anaesthesia, access and dress it with a corticosteroid + antibiotic paste, e.g. ledermix and seal with cotton wool and gic

contraindicated in under 12 due to tetracycline component can stain teeth
odontopaste alternative as doesn’t contain tetracycline

don’t prescribe antibiotics

Question 4

what is a characteristic feature of pulpal pain ?

Answer 4

unable to localise the affected tooth but the pain does not cross the midline as the pulp doesn’t contain any proprioceptive nerve endings

Question 5

how to come to a pulpal diagnosis

Answer 5

vitality tests help to some extent but

more defined by patient symptoms and history

Question 6

why should you be careful when sensibility testing and using these results?

Answer 6

these test the nerve supply- not the blood supply

blood supply is the indicator of vitality

Question 7

reversible pulpitis
radiographic signs

Answer 7

primary/secondary caries
no PA pathology

Question 8

irreversible pulpitis

meaning

Answer 8

severe inflammation of the pulp (the nerve and blood vessels inside a tooth) from which the pulp is unlikely to recover

will eventually progress to necrosis

Question 9

irreversible pulpitis

radiographic signs

Answer 9

deep caries/large restoration/crown

may see early PA changes, e.g. widening of the PDL

Question 10

cracked tooth syndrome

signs and symptoms
special tests
management

Answer 10

sharp pain on biting- clasically on release of bite
short duration
special tests: transillumination and tooth sleuth detects pain on release on biting
positive response to vitality testing
may be associated with bruxism

tx: requires coronal protection: onlay/crown

RCT may be required if crack extends into pulp

XLA as last resort
placement of orthodontic band around tooth can relieve symptoms and help with diagnosis

Question 11

characteristic patient sign of periapical periodontitis

Answer 11

PDL contains proprioceptive nerve endings, pt can identify the tooth causing pain + is localised

Question 12

pulp polyp

Answer 12

hyperplastic pulpitis
occurs as a result of proliferation of chronically inflamed young pulp tissue when exposed to the oral cavity

Question 13

pulp calcification

Answer 13

results in eventual occlusion of the pulp chamber by either physiological secondary dentine or tertiary dentine which is laid down in response to environmental stimuli as reactionary or reparative dentine

Question 14

reactionary vs reparative dentine

Answer 14

a response to a mild noxious stimulus whereas reparative dentine is deposited directly beneath the path of injured dentinal tubules as a response to strong noxious stimuli

Question 15

pt presents with:
pain on biting
very tender to put teeth together
disturbs sleep
TTP
dull ache exacerbated by biting down
deep carious crowned tooth
well localised

what is your diagnosis?

Answer 15

acute symptomatic periapical periodontitis

Question 15

periapical disease:

pathology

Answer 15

inflammation of the tissues surrounding the root caused by infection of the root canal system

endodontic biofilm is made primarily of gram negative bacteria. these organisms release virulence factors such as lipopolysaccharides inducing a host response which leads to inflammation, resorption of mineralised tissues surrounding the root,

Question 16

acute apical periodontitis

signs and symptoms
management

Answer 16

pain on biting
very tender to put teeth together
disturbs sleep
TTP
dull ache exacerbated by biting down
deep carious crowned tooth
well localised

usually no response to vitality testing unless multi rooted tooth one canal may be vital

may be a granuloma or cyst: periapical radiolucency, widening of PDL or loss of lamina dura

tx: RCT/XLA

Question 17

asymtomatic periapical periodotnitis

(chronic apical periodontitis)

Answer 17

does not give any positive signs of disease following examination apart from evidence of periapical inflammation

Question 18

acute periapical abscess

pathology

Answer 18

inflammatory response to microorgansims or their irritants have leached out into the periapical tissues

1. initial infection and inflammation of wbcs at site of infection
2. pulpal necrosis is a breeding ground for bacteira
3. infection spreads to periapical area and root apex
4. The inflammatory process in the periapical tissues causes cell death (necrosis) and a liquefaction process where dead tissue is broken down and converted into pus
5. The accumulated pus, along with bacteria, debris, and inflammatory cells, forms an abscess, which is a localised collection of pus within a tissue.

Question 19

acute periapical periodontitis:

pathology

Answer 19

chronic inflammation at the tip of a tooth root (periapical region) due to bacterial infection of the root canal system. This inflammation, a form of periapical periodontitis, can lead to liquefaction necrosis and eventually the formation of a granuloma. The process involves an initial inflammatory response, where cells like PMNs (polymorphonuclear leukocytes) infiltrate the area and cause tissue breakdown (liquefaction necrosis). If the inflammation persists, the body attempts to wall off the infected area, leading to the formation of a granuloma, which is a mass of inflammatory cells and surrounding fibrous tissue.

Question 20

acute apical abscess

signs and symptoms
radiographic signs

Question 21

acute periapical abscess

management

Question 22

when a patient who is immunocompromised and has a dental infection, what is important to consider?

Answer 22

infection may cause systemic sepsis

Question 23

signs of sepsis

Answer 23

altered mental state
rapid breathing and heart rate
failure to pass urine
low systolic blood pressure
non-blanching rash
cyanosis of the skin

temp of less than 36 degrees

Question 24

condensing osteitis

Answer 24

a diffuse increase in trabecular bone in response to irritation radiographically, a concentric radio-opaque area is seen around the offending root

Question 25

chronic periapical abscess

Answer 25

an inflammatory reaction to pulpal infection and necrosis characterised by gradual onset, little or no discomfort and an intermittent discharge of pus through a sinus tract or a periodontal pocket

Question 26

chronic periapical abscess signs and symptoms radiographic signs management

Answer 26

little or no discomfort discharge of pus may feel different on percussion, negative sensitivity tests sinus may be present signs of bone destruction/loss, defined periapical radiolucency. loss of lamina dura tx: XLA/RCT

Question 27

acute periapical abscess signs and symptoms radiographic signs

Answer 27

intense throbbing oain intra or extraoral swelling may feel unwell: malaise and systemic symtoms, e.g. pyrexia TTP tender to palpation and percussion negative sensitivity test tooth may be extruded/mobile fluctuant swelling present sensibility testing may be misleading as pus may conduct stimulus to apical tissues radiograph: may appear normal if rapid onset, may see periapical area or widening of PDL

Question 28

acute apical abscess management

Answer 28

check airway check for systemic symptoms: fever, malaise, swelling of face and neck, chills, aches, weakness is the tooth restorable? drain pus by accessing tooth to initiate abscess drainage through it- RCT. irrigate canal with sodium hypochlorite then dry and dress with non-setting calcium hydroxide if fluctuant swelling: incise and drain it. check and alleviate occlusion on affected tooth if appropriate prescribe analgesia if drainage not achieved or control post-op pain. nsaids prescribe antibiotics if signs of spreading or systemic infection if tooth unrestorable: extract the tooth and incise and drain fluctuant swelling when symptoms have subsided, commence RCT

Question 29

dentine hypersensitivity: signs and symptoms management

Answer 29

caused by exposed dentine resulting in pain in response to an external stimulus (touch/hot/cold) short sharp pain provoked by stimulus exposed root surface as a result of gingival recession tx: check for other causes of pain, e.g. reversible pulpitis fluoride varnish or dentine bonding agent to exposed dentine advise pt to avoid acidic foods and apply desensitising toothpaste to affected area with toothpaste

Question 30

perio endo lesion

Answer 30

inflammatory reactions originating in either the pulp or PDL with the potential of spread from one site to the other via a number of pathways: apical foramina, lateral and furcation accessory root canals, exposed dentinal tubules and root defects caused by caries, fractures or perforations

Question 31

periodontal abscess symtoms radiographic signs management

Answer 31

similar symptoms to acute periapical abscess with pain and tenderness but associated with a bad taste abscess develops in deep periodontal pockets where drainage is obstructed due to pocket marginal closure tooth mobile and TTP with associated localised or diffuse swelling of the periodontium deep periodontal pocket is associated and will extrude pus on probing presence of swelling on gingiva, suppuration from the gingiva , increased tooth mobility, fever radiograph: show vertical or horizontal bone loss and vitality tests are usually positive unless presence of perio endo lesion achieve drainage of pus irrigate with chlorhexidine systemic problem prescribe antibiotics (metronidazole or amoxicillin) debride the pocket once acute symptoms have settled extraction if poor prognosis scale teeth under LA, prescribe 0.2% chlorhexidine mouthwash for chemical plaque control request peridontal tx with hygienist if doesn't have GDP, recommend optimal analgesia don't prescribe antibiotics if there is not sign of spreading infeciton

Question 32

necrotising gingivitis causes what it is

Answer 32

severe gingival/periodontal inflammatory disease caused by fusiform bacteria and spirochetes affecting more commonly immunocompromised patients