Clinic, diagnostics of acute forms of pulpitis. Clinic, diagnostic of chronic forms of pulpitis and their exacerbation. Differential diagnostic of different.

Clinic, diagnostics of acute Clinic, diagnostics of acute forms of pulpitis. Clinic, forms of pulpitis. Clinic,

diagnostic of chronic forms diagnostic of chronic forms of pulpitis and their of pulpitis and their

exacerbation. Differential exacerbation. Differential diagnostic of different forms diagnostic of different forms

of pulpitis.of pulpitis.

IntroductionIntroduction

EndodonticsEndodontics is the specialty of is the specialty of dentistry that manages the dentistry that manages the preventionprevention, , diagnosisdiagnosis, and , and treatmenttreatment of the dental pulp and of the dental pulp and the periradicular tissues that the periradicular tissues that surround the root of the toothsurround the root of the tooth

Causes of PulpitisCauses of Pulpitis

1.1. Physical irritationPhysical irritation Most generally brought on by extensive decay.Most generally brought on by extensive decay.

2.2. TraumaTrauma Blow to a tooth or the jawBlow to a tooth or the jaw

3.3. AnachoresisAnachoresis

- retrograde infections- retrograde infections

Signs and SymptomsSigns and Symptoms

Pain when biting downPain when biting downPain when chewing Pain when chewing Sensitivity with hot or cold beverages Sensitivity with hot or cold beverages Facial swelling Facial swelling Discolouration of the toothDiscolouration of the tooth

Endodontic DiagnosisEndodontic Diagnosis

Subjective examinationSubjective examination Chief complaint Chief complaint Character and duration of pain Character and duration of pain Painful stimuli Painful stimuli Sensitivity to biting and pressureSensitivity to biting and pressure Discolouration of toothDiscolouration of tooth

Important questions?Important questions?

What do you think the problem is? What do you think the problem is? Does it hurt to hot or cold?  Does it hurt to hot or cold?  Does it hurt when you’re chewing? Does it hurt when you’re chewing? When does it start hurting? When does it start hurting? How bad is the pain?How bad is the pain? What type of pain is it? What type of pain is it? How long does the pain last?How long does the pain last? Does anything relieve it? Does anything relieve it? How long has it been hurting? How long has it been hurting?

Objective examinationObjective examination Extent of decayExtent of decay Periodontal conditions surrounding the Periodontal conditions surrounding the

tooth in questiontooth in question Presence of an extensive restoration Presence of an extensive restoration Tooth mobility Tooth mobility Swelling or discoloration Swelling or discoloration Pulp exposurePulp exposure

Challenges in diagnosis of pulpitisChallenges in diagnosis of pulpitis

Referred pain & the lack of proprioceptors in the pulp localizing the problem to the correct tooth can often be a considerable diagnostic challenge

Also of significance is the difficulty in relating the clinical status of a tooth to histopathology of the pulp in concern

Unfortunately, no reliable symptoms or tests consistently correlate the two.

Diagnostic TestsDiagnostic Tests

PercussionPercussion PalpationPalpation ThermalThermal ElectricalElectrical RadiographsRadiographs

1. Percussion tests1. Percussion tests

Used to determine whether the Used to determine whether the inflammatory process has extended inflammatory process has extended into the into the periapical tissuesperiapical tissues

Completed by the dentist tapping on the Completed by the dentist tapping on the incisal or occlusal surface of the tooth in incisal or occlusal surface of the tooth in question with the end of the mouth mirror question with the end of the mouth mirror handle held parallel to the long axis of the handle held parallel to the long axis of the toothtooth

Used to determine whether the Used to determine whether the inflammatory process has extended into inflammatory process has extended into the the periapical tissuesperiapical tissues

The dentist applies firm pressure to the The dentist applies firm pressure to the mucosa above the apex of the root mucosa above the apex of the root

2. Palpation tests2. Palpation tests2. Palpation tests2. Palpation tests

3. Thermal sensitivity3. Thermal sensitivity

Necrotic pulp will Necrotic pulp will notnot respond to cold respond to cold or hotor hot

1.1. Cold testCold test Ice, dry ice, or ethyl chloride used to Ice, dry ice, or ethyl chloride used to

determine the response of a tooth to determine the response of a tooth to coldcold

2.2. Heat testHeat test Piece of gutta-percha or instrument Piece of gutta-percha or instrument

handle heated and applied to the handle heated and applied to the facial surface of the toothfacial surface of the tooth

Evaluation of thermal test resultsEvaluation of thermal test results

4 distinct responses:4 distinct responses:

1.1. No responseNo response non-vital pulp or false non-vital pulp or false negativenegative

2.2. Mild responseMild response normalnormal

3.3. Strong but briefStrong but brief reversiblereversible

4.4. Strong but lingeringStrong but lingering irreversibleirreversible

Causes of false positives/negativeCauses of false positives/negative

1.1. CalcifiedCalcified canals canals

2.2. ImmatureImmature apex – usually seen in young apex – usually seen in young patientspatients

3.3. TraumaTrauma

4.4. PremedicationPremedication of the patient – pulp of the patient – pulp sedatedsedated

4. Electric pulp testing4. Electric pulp testing

Delivers a small electrical stimulus to Delivers a small electrical stimulus to the the pulppulp

Factors that may influence readings:Factors that may influence readings:Teeth with extensive restorationsTeeth with extensive restorationsTeeth with more than Teeth with more than one canalone canal Dying pulp can produce a variety of Dying pulp can produce a variety of

responsesresponses Moisture on the tooth during testingMoisture on the tooth during testingBatteries in the tester may be weakBatteries in the tester may be weak

Placement of a pulp tester.Placement of a pulp tester.

5. Radiographs5. Radiographs

1.1. Pre-operative radiographPre-operative radiograph Invaluable diagnostic toolInvaluable diagnostic tool Periapical radiolucencyPeriapical radiolucency Widening of PDLWidening of PDL Deep cariesDeep caries ResorptionResorption Pulp stonesPulp stones Large restorationsLarge restorations Root fracturesRoot fractures

Requirements of Endodontic FilmsRequirements of Endodontic Films

Show 4-5 mm beyond the apex of the Show 4-5 mm beyond the apex of the tooth and the surrounding bone or tooth and the surrounding bone or pathologic condition.pathologic condition.

Present an accurate image of the Present an accurate image of the tooth without elongation or fore-tooth without elongation or fore-shortening.shortening.

Exhibit good contrast so all pertinent Exhibit good contrast so all pertinent structures are readily identifiable.structures are readily identifiable.

Quality radiograph in endodontics.Quality radiograph in endodontics.

Diagnostic ConclusionsDiagnostic Conclusions

1.1. Normal pulpNormal pulp

2.2. PulpitisPulpitis

Normal pulpNormal pulp

There are no subjective symptoms or There are no subjective symptoms or objective signs. The pulp responds objective signs. The pulp responds normally to sensory stimuli, and a healthy normally to sensory stimuli, and a healthy layer of dentine surrounds the pulplayer of dentine surrounds the pulp

PulpitisPulpitis

The pulp tissues have become inflamedThe pulp tissues have become inflamed

Can be either:Can be either:

AcuteAcute

– – inflammation of the periapical area inflammation of the periapical area

– – usually quite painfulusually quite painful

ChronicChronic Continuation of acute stage orContinuation of acute stage or low grade infectionlow grade infection

Acute PulpitisAcute Pulpitis

mainly occurs in children teeth and mainly occurs in children teeth and adolescentadolescent

pain is more pronounced than in chronicpain is more pronounced than in chronic

Symptoms and SignsSymptoms and Signs of acute pulpitisof acute pulpitis

The pain not localized in the affected tooth is The pain not localized in the affected tooth is constant and throbbing worse by reclining or constant and throbbing worse by reclining or lying downlying down

The tooth becomes painful The tooth becomes painful with hot or cold stimuliwith hot or cold stimuli The pain may be sharp and stabbingThe pain may be sharp and stabbing Change of color is obvious in the affected toothChange of color is obvious in the affected tooth swelling of the gum or face in theswelling of the gum or face in the area of the affected tooth area of the affected tooth

Forms of acute pulpitisForms of acute pulpitis

1. Form of 1. Form of purulent acutepurulent acute where the pulp is where the pulp is totally inflammedtotally inflammed

2. Form of 2. Form of gangrenous acutegangrenous acute where the where the pulp begins to die in a less painful manner pulp begins to die in a less painful manner that can lead into the formation of an that can lead into the formation of an abscessabscess

Chronic PulpitisChronic Pulpitis

1.1. ReversibleReversible

2.2. IrreversibleIrreversible

Reversible pulpitisReversible pulpitis

The pulp is irritated, and the patient is The pulp is irritated, and the patient is experiencing pain to thermal stimuliexperiencing pain to thermal stimuli

Sharp shooting painSharp shooting painDuration of the pain episode lasts for

secondsThe tooth pulp can be savedUsually this condition is caused by

average caries

Irreversible pulpitisIrreversible pulpitis

The tooth will display symptoms of The tooth will display symptoms of lingering painlingering pain

pain occurs spontaneously or lingers pain occurs spontaneously or lingers minutes after the stimulus is removedminutes after the stimulus is removed

patient may have difficulty locating the tooth patient may have difficulty locating the tooth from which the pain originatesfrom which the pain originates

As infection develops and extends As infection develops and extends through the apical foramen, the tooth through the apical foramen, the tooth becomes exquisitely sensitive to becomes exquisitely sensitive to pressure and percussionpressure and percussion

A periapical abscess elevates the tooth A periapical abscess elevates the tooth from its socket and feels “high” when from its socket and feels “high” when the patient bites downthe patient bites down

Periradicular abscessPeriradicular abscess

An inflammatory reaction to pulpal An inflammatory reaction to pulpal infection that can be chronic or have infection that can be chronic or have rapid onset with rapid onset with painpain, tenderness of the , tenderness of the tooth to tooth to palpationpalpation and and percussionpercussion, pus , pus formation, and formation, and swellingswelling of the tissues. of the tissues.

An inflammatory reaction frequently An inflammatory reaction frequently caused by bacteria entrapped in the caused by bacteria entrapped in the periodontal sulcus for a long time. A periodontal sulcus for a long time. A patient will experience rapid onset, patient will experience rapid onset, painpain, tenderness to , tenderness to palpationpalpation and and percussionpercussion, pus formation, and , pus formation, and swellingswelling..

Destruction of theDestruction of the

periodontium occursperiodontium occurs

Periodontal abscessPeriodontal abscessPeriodontal abscessPeriodontal abscess

Periradicular cystPeriradicular cyst

A cyst that develops at or near the A cyst that develops at or near the root of a necrotic pulp. These root of a necrotic pulp. These types of cysts develop as an types of cysts develop as an inflammatory response to pulpal inflammatory response to pulpal infection and necrosis of the pulpinfection and necrosis of the pulp

Pulp fibrosisPulp fibrosis

The decrease of living cells The decrease of living cells within the pulp causing fibrous within the pulp causing fibrous tissue to take over the pulpal tissue to take over the pulpal canalcanal

Necrotic toothNecrotic tooth

Also referred to as Also referred to as non-vitalnon-vital.. Used Used to describe a pulp that does not to describe a pulp that does not respond to sensory stimulusrespond to sensory stimulus

Tooth is usually discolouredTooth is usually discoloured

Plan of TreatmentPlan of Treatment

Depends widely on the diagnosisDepends widely on the diagnosis

Simple plan of treatmentSimple plan of treatment

Visit 1Visit 1::

Medical historyMedical history History of the toothHistory of the tooth Access cavityAccess cavity Place rubberdamPlace rubberdam Extirpation + irrigation with sodium hypochloriteExtirpation + irrigation with sodium hypochlorite Placed intra-canal medication (calcium Placed intra-canal medication (calcium

hydroxide)hydroxide) Place cotton pelletPlace cotton pellet Placed temporary restoration (IRM/Kalzinol)Placed temporary restoration (IRM/Kalzinol)

Visit 2:Visit 2: Working length determinationWorking length determination Debridement using the hybrid techniqueDebridement using the hybrid technique IrrigationIrrigation Placed intra-canal medication (calcium Placed intra-canal medication (calcium

hydroxide)hydroxide) Place cotton pelletPlace cotton pellet Placed temporary restoration (IRM/Kalzinol)Placed temporary restoration (IRM/Kalzinol)

Visit 3:Visit 3:Obturation of the canal using lateral Obturation of the canal using lateral

condensationcondensation

Placed temporary/permanent Placed temporary/permanent restoration (IRM/Kalzinol) restoration (IRM/Kalzinol)

ReferralReferral

To appropriate disciplineTo appropriate discipline

Remember Remember

Access cavity shapes:Access cavity shapes:1.1. Anterior – inverted triangleAnterior – inverted triangle2.2. Premolars – roundPremolars – round3.3. Molars – rhomboidMolars – rhomboid Always use rubberdamAlways use rubberdam Never to use Cavit as a temporary restorationNever to use Cavit as a temporary restoration Always place an intra-canal Always place an intra-canal

medication….calcium hydroxide!!!medication….calcium hydroxide!!! Always use RC Prep or Glyde when filingAlways use RC Prep or Glyde when filing

Contraindications for RCTContraindications for RCT

Caries extending beyond bone levelCaries extending beyond bone level Rubberdam cannot be placedRubberdam cannot be placed Crown of tooth cannot be restored in restorative dentistry Crown of tooth cannot be restored in restorative dentistry

nor prosthodonticsnor prosthodontics Patient is physically/mentally handicapped and therefore Patient is physically/mentally handicapped and therefore

cannot follow OH instructionscannot follow OH instructions Putrid OHPutrid OH Unmotivated patientUnmotivated patient Severe root resorptionSevere root resorption Vertical root fracturesVertical root fractures Cost factorCost factor

Inter & cross-departmental diagnosisInter & cross-departmental diagnosis

Mobile teeth Mobile teeth Teeth associated with severe periodontal Teeth associated with severe periodontal

problemsproblems Confusion between TMJ dysfunctional Confusion between TMJ dysfunctional

symptoms and RCT painsymptoms and RCT pain Many decayed teethMany decayed teeth Sclerosed canal due to traumaSclerosed canal due to trauma Uncertainty of prognosis related to abscess, Uncertainty of prognosis related to abscess,

severe caries, facial swelling, cellulites, and severe caries, facial swelling, cellulites, and medical condition of patientmedical condition of patient

Referral to post-grad clinicsReferral to post-grad clinics

Extensive internal or external root Extensive internal or external root resorptionresorption

Severely curved, narrow, tortuous canalsSeverely curved, narrow, tortuous canalsFull-mouth rehabilitation requiredFull-mouth rehabilitation requiredMultiple exposures due to Multiple exposures due to

attrition/abrasion attrition/abrasion Problems with occlusion causing the need Problems with occlusion causing the need

for RCTfor RCT

PULPAL DISEASE

Classified as:

Reversible pulpitis

Irreversible pulpitis

Necrotic pulp

Pulpal Disease

Reversible

Pulpitis

Reversible Pulpitis

Condition should return to normal with removal of the cause.

Common causes: Caries, recent restorative procedures, faulty

restorations, trauma, exposed dentinal tubules, periodontal scaling.

Pulpal recovery will occur if reparative cells in the pulp are adequate.

Symptoms of Reversible Pulpitis

Thermal: Hypersensitive with mild pain of <30 seconds, but

similar to control tooth

Sweets: Sensitive (if caries, crack, or exposed dentin) with mild

pain of <30 seconds (similar to control tooth)

Biting Pressure: None (unless tooth is cracked)

Clinical Findings inReversible PulpitisVisual Check for decay, fracture lines, swelling, sinus tracts,

orientation of tooth, and hyperocclusion

Palpation Not sensitive

Percussion Not sensitive

Mobility None (unless periodontal condition exists)

Perio probing WNL (unless concomitant periodontal disease exists)

Thermal Hypersensitive to heat or cold

EPT Responds

Translumination Not used unless a fracture is suspected

Selective anesthesia

Not necessary

Test cavity Not necessary, tooth is vital

Radiographic Periapical x-ray shows normal periapex

DiagnosisReversible Pulpitis

If there is a discrepancy between the patient’s chief complaint, symptoms, and clinical examination – obtain more information or data interpretation.

Remember: both a preoperative pulpal and periapical diagnosis are made before treatment is initiated (if reversible pulpitis is only condition, the periapical area should be normal).

If the tooth is percussion sensitive – consider bruxism or hyperocclusion.

Pulpal Disease

Irreversible

Pulpitis

Irreversible Pulpitis

Pulpal inflamation and degeneration not expected to improve.

A physiologically older pulp has less ability to recover due to decrease in vascularity and reparative cells.

As inflammation spreads apically, cellular organization begins to break down.

Localized pressure slows venous return, resulting in buildup of toxins and lower pH that causes widespread cellular destruction.

Symptoms of Irreversible Pulpitis

Thermal: Hypersensitive with moderate to severe

prolonged pain (>30 seconds) as compared to the control

Sweets: Moderately to severely sensitive (if caries,

crack, or exposed dentin)Biting Pressure:

Usually sensitive in later stages (periapical symptom)

Moderate to severe spontaneous pain

Clinical Findings inIrreversible Pulpitis

Visual Check for decay, fracture lines, swelling, sinus tracts, orientation of tooth, and hyperocclusion

Palpation No response initially; may be sensitive in later stages

Percussion No response initially; may be sensitive in later stages

Mobility None (unless periodontal condition exists)

Perio Probing WNL ( unless concomitant periodontal disease exists)

Thermal Hypersensitive to hot and cold with prolonged response

EPT Responds

Translumination Not used unless fracture is suspected

Selective

Anesthesia

May help identify offending tooth

Test cavity Not necessary, tooth is vital

Radiographic Normal or thickened periodontal ligament

DiagnosisIrreversible Pulpitis

Hypersensitive to hot or cold that is prolonged.

A history of spontaneous pain.

Vital or partially vital pulp.

Pulpal Disease

Necrotic

Pulp

Necrotic Pulp

Results from continued degeneration of an acutely inflamed pulp.

Involves a progressed breakdown of cellular organization and no reparative potential.

Commonly have apical radiolucent lesion. (always conduct proper pulp testing to rule out a non-pulpal origin).

With multi-rooted teeth, one root may contain partially vital pulp, whereas other roots may be nonvital (necrotic).

Maxillary first molar with large amalgam restoration and periapical radiolucencies around all three roots. The tooth was unresponsive to electrical and thermal testing.

Periapical radiolucency of canine and premolar. The canine was responsive to pulp and thermal testing.

Symptoms of Necrotic Pulp

Thermal: No response

Sweets: No response

Biting Pressure: Usually moderate to severe pain (not symptom of

necrotic pulp, but rather periapical inflammation)

Moderate to severe spontaneous pain (usually dull and throbbing; associated with periapical area)

Clinical Findings inNecrotic Pulp

Visual Check for decay, fracture lines, swelling, sinus tracts, orientation of tooth, and hyperocclusion

Palpation Sensitive

Percussion Mild to severe pain (depends on periapex inflammation)

Mobility None to moderate (depends on bone loss)

Perio Probing WNL ( unless concomitant periodontal disease exists)

Thermal No response

EPT No response

Translumination Not used unless fracture is suspected

Selective anesthesia

May help identify offending tooth

Test cavity May be used if vitality is suspected

Radiographic Periapical radiograph may show normal or thickened periodontal ligament, or radiolucent lesions

chronic pulpitis with a closed pulp chamber

chronic ulcered pulpitis hyperplastic pulpitis residual pulpitis retrograde pulpitis

Chronic pulpitis

chronic pulpitis with a closed pulp chamber

---deep caries/recurrent caries extensive restorations(near the chamber)---detection: bluntness/inaction ---percussion: (+) ---pulp test: no-reaction/slow-reaction---radiogralph:“thicken” periodontal membrane

chronic ulcered pulpitis

---typical complain painful when compressed by food packed into the cavity

---pulp chamber opened and ulcered pulp

---detection: pain and bleeding

---percussion: (+)

hyperplastic pulpitis

---typical complain, bleeding when chewing

---pulp polyp

---tartar in the same side

---in young people

---distinguish from the other polyp

residual pulpitis

---treated tooth (uncomfortable treatment)

missing canal, residual pulp

---percussion: (+)

---pulp test(strong): slow-reaction

---radiogralph:“thicken” periodontal membrane

---final decision: painful when canal detection

retrograde pulpitis

---pulpitis and periodontitis

---deep periodontal pocket

---percussion: (+~++)

---pulp test: difference

---radiogralph ： radiolucency around

the root and furcation

Electric pulp testing

‡Delivers a high frequency current to desired tooth.

‡To determine the presence or absence of sensory nerves (pulp vitality).

Stimulated nerves are of the myelinated A-delta fiber group.

How to perform EPT ?

‡Clean, dry & isolate tooth.

Scrub facial surface with a dry cotton roll and isolate with the same roll.

‡Make sure tooth is dry by air syringe. ‡Attach the clip of the device to patients lip or let

him hold it( closes the electrical circuit). ‡Apply toothpaste or conducting medium to the

electrode & touch tooth. ‡A control test must be performed on a non

affected tooth to make sure patient has a normal threshold of stimulation

Differential diagnosis

Acute pulpitis

(pain is spontaneous and more intense)Deep situated carious lesion( pulp is stimulated in the same way but

stimulus subsides immediately)

Differential diagnosis

Pulp necrosis

( same symptoms but pain is only triggered on hot irritant, also a continuity between cavity and pulp exists )

Prognosis of untreated teeth:

‡Inflamed tissue will change into granulation tissue due to persistent irritation.

‡Later on fibrous tissue will form. ‡From this point several pathologies may arise-necrosis-internal resorption-calcification of pulp chamber -pulpal stones It is important to keep in mind that a chronic form

may turn to the acute form in cases of decreased immunity.

Questions????Questions????