clinical signs and symptoms of pulp and periapical disease 4.11
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11/4/10
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Clinical signs & symptoms and the diagnosis of
pulpal disease and periapical infection
Mr S Godfrey
Surface biofilm
Cervical seal
Alveolar bone
Periodontal ligament
Dentine
Pulpal Tissue
Enamel mantle
Oral fluids
Nerve supply
Arterial supply
Venous drainage
Pulpal tissue ! Blood supply ! Nutrients ! Immune factors ! Nerve supply ! Controls enamel
fluid flow ! Important in
mineralisation ! Essential for
proper physiological functioning of dentine and enamel
! ˚C
+5˚C
Reactive Calcification
Pulp chamber reduced in size by reactionary and secondary dentine
Leakage
Remains of old restoration
Reactive Calcification
Dead tracts
Cavitation
Dead tracts
Enam
el
Lingual Labial
Area of demineralisation
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Determining the status of the pulp
Pulp status
• Alive • Vital • Healthy
• Pulpless • Non-vital • Dead • Moribund • Necrotic • Septic • Gangrenous
Pulp status
• Alive & healthy
• Inflammed & of undetermined prognosis
• Non-vital & requiring treatment
Pulpal Inflammation - Pulpitis
Reversible or Irreversible
Pulpal Inflammation - Pulpitis
Reversible or Irreversible
Cardinal symptom is pain
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Pulpal Inflammation - Pulpitis
Reversible or Irreversible
Painful pulps during caries excavation and restoration removal, covered by dentine. (Provisional diagnosis)
Painful pulps plus a carious pulpal exposure & broken dentine barrier.
Diagnosis is aimed at establishing a prognosis
Viable Treatment aimed at maintenance of vitality
Non-viable In need of pulpectomy
Pulp Status
Pulp Status – Non Vital
Pulpal necrosis – Insensitive to vitality testing – The crown is discoloured (greyish)
Periapical inflammation (+/- Abscess): – Insensitive to vitality testing – Dull, continous pain – Intra- or extra-oral swelling – Draining Fistula or sinus tract – Periapical radiolucency
Pulp testing • Thermal – hot
• Thermal – cold
• Electrical
Pulpectomy and RCT
Aim To eliminate root canal infection
Pulpectomy and RCT
‘The ultimate biologic aim of endodontics is to prevent or
cure apical periodontitis’
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Scheme for Routine RCT
1. Assessment, prior to treatment 2. Provision of safe and aseptic field of
operation 3. Gaining access to the pulp chamber and
identification of the canals 4. Mechanical instrumentation of the canal
interior
Scheme for Routine RCT
5. Irrigation of canal network with disinfectants
6. Placing an anti-bacterial dressing between appointments
7. Filling of canal network (obturation) 8. Assessment of the initial treatment and
after 6/12
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Pulp
The first line of defence against infection
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How do bacteria gain access to the pulp space?
CARIES
Cavity prep
Microleakage around restorations
Cracks
Heat – Trauma – Dessication
Periodontal defects
Bacteria and their by-products give rise to pulpal
inflammation
Pulpal inflammation will result in a lower threshold to nerve pathway firing, resulting
in pain to otherwise non-painful stimuli
Microbial products react with pulp
Selection – sticky bacteria
Pulp necrosis Necrotic foci
Clinical signs and symptoms of reversible pulpal inflammation
• Sensitivity to temperature changes • Sensitivity to sweet
• Mild – check the pain scale • Transient • Short duration • Provoked
Test with cold or heat to find the tooth Or the patient may know- beware!
SYMPTOMATIC REVERSIBLE PULPITIS
Pulpitis is, as a rule, painless.
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CLINICAL DIAGNOSTIC TESTS
• THERMAL TESTS • ELECTRIC • PERCUSSION • BITING • PALPATION • TRANSILLUMINATION • TEST CAVITY
CLINICAL DIAGNOSTIC TESTS
• THERMAL TESTS • ELECTRIC • PERCUSSION • BITING • PALPATION • TRANSILLUMINATION • TEST CAVITY
Isolate the tooth
Take your time between teeth!
Cold Tests – Ethyl Chloride
Heat tests
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CLINICAL DIAGNOSTIC TESTS
• THERMAL TESTS • ELECTRIC • PERCUSSION • BITING • PALPATION • TRANSILLUMINATION • TEST CAVITY
Electric Pulp Tester
Gradations of electrical current are used to stimulate nervous
tissue within the pulp
CLINICAL DIAGNOSTIC TESTS
• THERMAL TESTS • ELECTRIC • PERCUSSION • BITING • PALPATION • TRANSILLUMINATION • TEST CAVITY
Percussion CLINICAL DIAGNOSTIC TESTS
• THERMAL TESTS • ELECTRIC • PERCUSSION • BITING • PALPATION • TRANSILLUMINATION • TEST CAVITY
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Tests for Cracks
TOOTH SLEUTH
Sharp pain on release of pressure indicates a crack
Tests for Cracks
Tongue Spatula
Tests for Cracks
Tongue Spatula
Sharp pain on release of pressure indicates a crack
CLINICAL DIAGNOSTIC TESTS
• THERMAL TESTS • ELECTRIC • PERCUSSION • BITING • PALPATION • TRANSILLUMINATION • TEST CAVITY
Palpation
Palpation is used as part of a physical examination in which an object is felt to determine its size,
shape, firmness, or location.
Palpate over the apices to check for
a) apical inflammation b) pus production
Palpate to check mobility
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CLINICAL DIAGNOSTIC TESTS
• THERMAL TESTS • ELECTRIC • PERCUSSION • BITING • PALPATION • TRANSILLUMINATION • TEST CAVITY
Transillumination
Transillumination CLINICAL DIAGNOSTIC TESTS
• THERMAL TESTS • ELECTRIC • PERCUSSION • BITING • PALPATION • TRANSILLUMINATION • TEST CAVITY
Clinical signs and symptoms of pulpal inflammation-worsening!
Sensitivity is increasing on the pain scale
Painful for a few seconds and then subsides
Longer duration- >30 seconds -maybe left with an ache
? Tender to Percussion – TTP ?
Provoked
Clinical signs and symptoms of pulpal inflammation-worsening!
Sensitivity is increasing on the pain scale
Painful for a few seconds and then subsides
Longer duration- >30 seconds -maybe left with an ache
? Tender to Percussion – TTP ?
Provoked
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Clinical Case 40 year old male-regular attender
Not much history of dental work
Aching from upper left quadrant-25,26 region
Started 14 days ago -slowly worsening
Temperature changes bring it on
Registers 5 on the pain scale
Subsides to 2 or 3 after 10 seconds
No pain at present
Reversible to
Irreversible Pulpitis
This can be the most difficult diagnosis in conservative dentistry…..
and the diagnosis is irreversible!
Symptomatic Irreversible Pulpitis
Discomfort increasing on the pain scale : 5+
Very painful for 10 secs and subsides to a throb
Residual throb can last one minute to an hour or more
Tender to Percussion – TTP
Spontaneous- no provocation
Woken at night
Radiating pain
Symptomatic Irreversible Pulpitis
Pain and the pulp is dying!
Asymptomatic Irreversible Pulpitis
No pain but the pulp is dying!
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Pulpitis is, as a rule, painless. Diagnostic Warning Signs of
Damaged Pulps Deep restorations
Large /multiple restorations
Crowns, inlays, onlays
Decay
Deep bases
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Diagnostic Warning Signs
Pulp stones indicate;
Previous trauma
Occlusal parafunction
© 2003 Challenging Courses
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Diagnostic Warning Signs
Chamber constriction – canal constriction
“Width of the pulp chamber or root canal as seen on a radiograph, affords significant information of the status of the pulp. Excessively narrowed or widened pulp spaces, when compared to those of adjacent teeth, are definite indications of pulp pathosis”
Sheffield 2002 Challenging Courses © 2002
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Development of an ECOSYSTEM and formation of BIOFILM
Evolving environment with competition amongst species
Events following pulp necrosis
Invasion of the pulp chamber space by microbes
The Periapex
2nd line of defence
TISSUE FLUIDS
INFLAMMATORY EXUDATE
IMMUNE CELLS
Apical Periodontitis
Apical Periodontitis
Apical Periodontitis
OR perhaps
Peri-radicular periodontitis?
Asymptomatic or symptomatic
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Symptomatic Apical Periodontitis Tender to percussion
Tender to palpation especially over the apices
Swelling and reddening of the mucosa
No responses to vitality testing
Pain can be severe especially in function or pressure
Can be CONSTANT and worsening
Can be present for several hours
Palpate
Percussion Normal appearance of
healthy tissues
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Challenging Courses © 2003
Clinical signs & symptoms and the diagnosis of
pulpal disease and periapical infection
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