Toothaches of Dental Origin Diagnosis and Management Material used by permission from B.C. Decker Publishing Co.

Initial Guidelines Before treating, determine a separate pulpal and periapical diagnosis based on history and responses to clinical tests. Focus first on pulpal signs and symptoms, and then periapical signs and symptoms. Pulpal inflammation can eventually result in periapical inflammation. A tooth with a large periapical radiolucency must have a necrotic pulp, if the lesion is of endodontic origin.

Guidelines, con’t. Post-op pain management for patients requiring a pulpotomy or pulpectomy: Pre-emptive analgesia: prior to the procedure, give the patient ibuprofen 600mg plus acetaminophen 1000mg, orally. Contraindications: hypersensitivity to NSAIDs or ASA, pregnancy, asthma, CHF, hypertension, decreased renal or hepatic function, GI bleeding or ulcers, or those on anticoagulant drugs. Injection of 0.5% marcaine following the procedure.

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 in Reversible Pulpitis Visual Check for decay, fracture lines, swelling, sinus tracts, orientation of tooth, and hyperocclusion Palpation Not sensitive Percussion 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

Diagnosis Reversible 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.

Treatment of Reversible Pulpitis Remove irritant if present (caries; fracture; exposed dentinal tubules). If no pulp exposure: CaOH, restore, monitor If pulp exposure: Carious: initiate RCT Mechanical: >1 mm: initiate RCT <1 mm crown planned: initiate RCT <1 mm: direct cap or RCT If recent operative or trauma – postpone additional treatment and monitor.

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 in Irreversible 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 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

Diagnosis Irreversible Pulpitis Hypersensitive to hot or cold that is prolonged. A history of spontaneous pain. Vital or partially vital pulp.

Treatment of Irreversible Pulpitis Minimum immediate treatment (if not extraction) Pulpotomy: Remove all decay (essential) Large canals: passively broach 75% of tooth length Small canals: spoon excavate orifice while removing pulpal tissue from chamber. Copious irrigation with sodium hypochlorite (1%). Dry chamber with cotton pledget Place Ca(OH)² into large and over small canals Place dry cotton pellet in chamber, cover with cavit, temporarily restore with Ketac-fill; completely relieve occlusion if have acute apical peridontitis

Treatment of Irreversible Pulpitis Ideal immediate treatment Pulpectomy (complete removal of pulpal tissue) Determine the ideal working length (WL) Fully instrument canals with master apical file At least # 25 file for small canals (and anterior teeth) # 35 - 40 file for larger canals Alternate working files with #8 or 10 patency file Copious irrigation with sodium hypochlorite (1%) Dry chamber with cotton pledget Place dry cotton pellet over canals, cover with cavit, temporarily restore with Ketac-fill; completely relieve occlusion if have acute periapical peridontitis.

Ideal Access Preparations

Irreversible Pulpitis (more treatment considerations) Any residual decay can result in an inadequate seal, contamination of canal space, and inter-appointment flare-ups. Inflammation can be judged by the amount of hemorrhage from the remaining pulp stump. If bleeding continues, re-broach or file for residual pulpal tags with copious irrigation. To decrease risk of instrument separation within the canal space, do not engage the canal walls with broach.

Irreversible Pulpitis (additional considerations) Do not leave teeth open between appointments – causes contamination of the canals and difficulty closing them later. Incomplete tooth fractures involving the pulp will show symptoms of irreversible pulpitis. Periodontal probing of associated pocket will indicate depth of fracture. If depth of pocket (fracture) extends below the attachment level, the prognosis is guarded to poor.

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

Symptoms of Necrotic Pulp Thermal: No response Sweets: 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 in Necrotic 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 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

Diagnosis of Necrotic Pulp Distinguishing features: No response to cold. No response to EPT. Caveats Decreased sensitivity to cold/ept may be from of insulating effects of additional dentin. Fluid in canal space conducting electrical current can give false-positive. Periapical radiolucency is strong but not conclusive evidence that pulp is necrotic.

Treatment of Necrotic Pulp Minimum immediate treatment (if not extraction) Partial instrumentation of canals: Remove all decay, evaluate restorability Determine working length of all canals Large canals: up to #40 file, 4mm short of WL Small canals: up to #25 file, 4mm short of WL Alternate working file with #8 or 10 patency file Copious irrigation with sodium hypochlorite (1%) Dry chamber with cotton pledget Place Ca(OH)² into all canals Place dry cotton pellet in chamber, cover with cavit, temporarily restore with Ketac-fill; completely relieve occlusion if have acute apical periodontitis.

Treatment of Necrotic Pulp Ideal immediate treatment Complete instrumentation of canals: Determine the ideal working length Fully instrument canals with master apical file At least # 25 file for small canals (and anterior teeth) # 35 - 40 file for larger canals Alternate with #8 or 10 patency file Copious irrigation with sodium hypochlorite (1%) Place dry cotton pellet over canals, cover with cavit, temporarily restore with Ketac-fill; completely relieve occlusion if have acute apical periodontitis.

Necrotic Pulp (additional considerations) Antibiotic coverage Usually not required unless patient has progressive swelling or fever. Pain Management Always determine allergy, contraindication, and interaction with present medications Clock regulate NSAID (ibuprofen) for 3 days Narcotic for approximately 3 days, if needed Occlusal Reduction Reduction in all cases with acute apical periodontitis (remember that length measurements may change)

PERIAPICAL DISEASE Classified as: Acute Apical Periodonitis Acute Apical Abscess Chronic Apical Periodontitis (Suppurative Apical Periodontitis with sinus tract) Condensing Osteitis

Treatment of Periapical Disease Pulpal status always dictates treatment of periapical disease

Periapical Disease Acute Apical Periodontitis

Acute Apical Periodontitis Mild to severe inflammation that surrounds or is closely associated with the apex of a tooth. Results from: Irreversible inflammation or necrotic pulp. Trauma or bruxism of normal or reversibly inflamed pulpitic conditions. Consider vertical fractures, periodontal abscess, and non-odontogenic pain.

Clinical Findings in Acute Apical Periodontitis Visual Check for decay, fracture lines, swelling, sinus tracts, orientation of tooth, and hyperocclusion Palpation Sensitive (usually on buccal surface) Percussion Moderate to severe (initially use index finger to reduce patient discomfort) Mobility Slight to no mobility (if moderate mobility exists, check for possible periodontal condition before continuing)

Acute Apical Periodontitis, con’t. Perio Probing WNL (unless concomitant periodontal disease or vertical fracture exists) Thermal (pulpal symptom) Response (not prolonged) – consider traumatic occlussion If response prolonged – consider irreversible pulpitis No response – consider necrotic pulp EPT (pulpal test) Response – pulp is vital (reversible or irreversible) No response – pulp is necrotic

Acute Apical Periodontitis, con’t. Translumination Not used unless fractured is suspected Selective Anesthesia Not necessary, offending tooth easily located Test cavity Not necessary Radiographic Periapical image does not show a radiolucent lesion; some thickening of the periodontal ligament is common

Immediate Treatment of Acute Periapical Periodontitis If from irreversible pulpitis: Pulpotomy or extraction. If from necrotic pulp: Root canal therapy initiated or extraction. If from hyperocclusion: When the pulp is normal or reversibly inflamed, adjusting the occlusion provides immediate relief. Always consider cracked tooth, irreversible pulpitis, or necrotic pulp if discomfort persists. If from bruxism: A biteguard may be indicated.

Periapical Disease Acute Apical Abscess

Acute Apical Abscess Acute inflammation of the periapical tissue characterized by localized accumulation of pus at the apex of a tooth. A painful condition that results from an advanced necrotic pulp. Patients usually relate previous painful episode from irreversible or necrotic pulp. Swelling, tooth mobility, and fever are seen in advanced cases.

Symptoms of Acute Apical Abscess Spontaneous dull, throbbing, persistent pain; exacerbated by lying down. Percussion: Extremely sensitive Mobility: Horizontal / vertical; often in hyperocclusion Palpation: Sensitive; vestibular or facial swelling likely Thermal: No response

Clinical Findings of Acute Apical Abscess Visual: Check for decay, fracture lines, swelling, sinus tracts, orientation of tooth, hyperocclusion Palpation: sensitive; intraoral or extraoral swelling present Percussion: Moderate to severe (initially use index finger) Mobility: Slight to none; may be compressible Perio probing: WNL (unless have perio disease or vertical fracture)

Acute Apical Abscess, con’t. Thermal: No response (pulp is necrotic) EPT: No response (false-positive from fluid in canal) Translumination: Not used unless fractured is suspected Selective Anesthesia: Not necessary, offending tooth easily located Test cavity: Not necessary unless vitality is suspected

Acute Apical Abscess, con’t. Radiographic: Thickening of the periodontal ligament is common; may not show a frank lesion If tests indicate pulp vitality: (red flag!) Review diagnostic information (repeat diagnostic tests) Rule out lateral periodontal abscess Review medical history for previous malignant lesions or other conditions (hyperparathyroidism) that may explain contradictory information Do not begin treatment until this discrepancy has been resolved

Treatment of Acute Apical Abscess (necrotic pulp) Minimum immediate treatment (if not extraction) Partial instrumentation of canals: Remove all decay, evaluate restorability Determine working length of all canals Achieve apical patency all canals with #10 file, look for drainage and allow to continue until it stops Large canals: up to #40 file, 4mm short of WL Smaller canals: up to #25 file, 4mm short of WL Alternate with #8 or 10 patency file Copious irrigation with sodium hypochlorite (1%) Dry chamber with cotton pledget continued on next slide

Treatment of Acute Apical Abscess, con’t. Place Ca(OH)² into all canals Place dry cotton pellet in chamber, cover with cavit, temporarily restore with Ketac-fill, and completely relieve tooth from occlusion. Incision and drainage may be required Prescribe antibiotics and analgesics Continued pain and swelling are common postoperative problems – so prepare the patient for several days of discomfort.

Periapical Disease Chronic Apical Periodontitis

Chronic Apical Periodontitis Results from prolonged inflammation that has eroded the cortical plate making a periapical lesion visible on the radiograph. Caused by a necrotic pulp, the lesion contains granulation tissue consisting of fibroblasts and collagen (with macrophages and lymphocytes). Must rule out central giant cell granuloma, traumatic bone cyst, and cemental dysplasia. Usually asymptomatic, but in acute phase may cause a dull, throbbing pain.

Chronic apical periodontitis Chronic apical periodontitis. Extensive tissue destruction in the periapical region of a mandibular first molar occurred as a result of pulpal necrosis. Lack of symptoms together with presence of a radiographic lesion is diagnostic.

Chronic Apical Periodontitis, con’t. Most common pitfall is assuming that the presence of a periapical lesion automatically indicates a necrotic pulp. If tests indicate pulp vitality: (red flag!) Review diagnostic information (repeat diagnostic tests) Rule out lateral periodontal abscess, central giant cell granuloma, traumatic bone cyst, and cemental dysplasia. Review medical history for previous malignant lesions or other conditions (hyperparathyroidism) that may explain contradictory information Do not begin treatment until this discrepancy has been resolved

Periapical radiolucencies associated with mandibular incisors Periapical radiolucencies associated with mandibular incisors. These teeth were vital, and a diagnosis of cemental dysplasia was made.

Treatment of Chronic Apical Periodontitis (necrotic pulp) If asymptomatic, no immediate treatment needed; schedule for root canal therapy If in acute suppurative phase, immediate treatment same as with acute apical abscess, i.e., Partial instrumentation of canals: Remove all decay, evaluate restorability Determine working lengths of all canals Achieve apical patency all canals with #10 file, look for drainage and allow to continue until it stops Large canals: up to #35 file, 4mm short of WL Smaller canals: up to #25 file, 4mm short of WL Alternate with #8 or 10 patency file

Treatment of Chronic Apical Periodontitis, con’t. Copious irrigation with sodium hypochlorite (1%) Dry chamber with cotton pledget Place Ca(OH)² into all canals Place dry cotton pellet in chamber, cover with cavit, temporarily restore with Ketac-fill, and completely relieve tooth from occlusion. Incision and drainage may be required Prescribe antibiotics and analgesics Continued pain and swelling are common postoperative problems – so prepare the patient for several days of discomfort.

Periapical Disease Condensing Osteitis

Condensing Osteitis Increased trabecular bone in response to persistent irritant diffusing from the root canal into the periradicular tissue. May be either asymptomatic (pulpal necrosis) or associated with pain (pulpitis). Therefore, may or may not respond to diagnostic tests, i.e., thermal, electric, palpation, percussion. Root canal treatment, when indicated, may result in complete resolution.

Inflammation followed by necrosis in the pulp of the first molar has resulted in the diffuse radiopacity of the periradicular tissue.