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Clinical signs & symptoms and the diagnosis of pulpal disease and periapical infection Mr S Godfrey

Surface biofilm

Oral fluids Pulpal tissue ! Enamel mantle Blood supply

Cervical seal

! ! ! !

Nutrients Dentine Immune factors Nerve Tissue Pulpalsupply Controls enamel

fluid flow mineralisation ligament physiological Venous drainage functioning of dentine and C enamel

!Periodontal Important in
Alveolar bone

! Essential for

proper Arterial supply

Nerve supply

+5C

Cavitation Dead tracts

Area of demineralisation

En am

el

Reactive Calcification

Remains of old restoration Leakage

Pulp chamber reduced in size by reactionary and secondary dentine Lingual

Dead tracts Reactive Calcification Labial

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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

infe

Non-vital & requiring treatment

-moribund: dying -septic:infected -gangrenous:necrosis of soft tissues due to poor blood circulation

Pulpal Inflammation - Pulpitis

Pulpal Inflammation - Pulpitis

Reversible or Irreversible

Reversible or Irreversible Cardinal symptom is pain

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Pulpal Inflammation - Pulpitis

Pulp Status
Diagnosis is aimed at establishing a prognosis

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.

Viable

Treatment aimed at maintenance of vitality

Non-viable

In need of pulpectomy

Pulp Status Non Vital

Pulpal necrosis
Insensitive to vitality testing The crown is discoloured (greyish)

Pulp testing
Thermal hot Thermal cold Electrical

Periapical inflammation (+/- Abscess):

Insensitive to vitality testing Dull, continous pain Intra- or extra-oral swelling Draining Fistula or sinus tract Periapical radiolucency

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. 2. 3. 4. Assessment, prior to treatment Provision of safe and aseptic field of operation Gaining access to the pulp chamber and identification of the canals Mechanical instrumentation of the canal interior 5. 6. 7. 8.

Scheme for Routine RCT

Irrigation of canal network with disinfectants Placing an anti-bacterial dressing between appointments Filling of canal network (obturation) 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

Microbial products react with pulp

Necrotic foci

Pulp necrosis

Pulpal inflammation will result in a lower threshold to nerve pathway firing, resulting in pain to otherwise non-painful stimuli

Selection sticky bacteria

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!

Pulpitis is, as a rule, painless.

SYMPTOMATIC REVERSIBLE PULPITIS

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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

Cold Tests Ethyl Chloride

Isolate the tooth Take your time between teeth!

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

Tests for Cracks

Tongue Spatula

Sharp pain on release of pressure indicates a crack

Tests for Cracks

Tongue Spatula

CLINICAL DIAGNOSTIC TESTS

THERMAL TESTS ELECTRIC PERCUSSION BITING PALPATION TRANSILLUMINATION TEST CAVITY

Sharp pain on release of pressure indicates a crack

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 to check mobility

Palpate over the apices to check for a) apical inflammation b) pus production

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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

Asymptomatic Irreversible Pulpitis

Pain and the pulp is dying!

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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Events following pulp necrosis The Periapex

Invasion of the pulp chamber space by microbes Development of an ECOSYSTEM and formation of BIOFILM TISSUE FLUIDS Evolving environment with competition amongst species INFLAMMATORY EXUDATE IMMUNE CELLS

2nd

line of defence

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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