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

Introduction Endodontics is the specialty of dentistry that manages the prevention, diagnosis, and treatment of the dental pulp and the periradicular tissues that surround the root of the tooth

Causes of Pulpitis Physical irritation Trauma Anachoresis Most generally brought on by extensive decay. Trauma Blow to a tooth or the jaw Anachoresis - retrograde infections

Signs and Symptoms Pain when biting down Pain when chewing Sensitivity with hot or cold beverages Facial swelling Discolouration of the tooth

Endodontic Diagnosis Subjective examination Chief complaint Character and duration of pain Painful stimuli Sensitivity to biting and pressure Discolouration of tooth

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

Objective examination Extent of decay Periodontal conditions surrounding the tooth in question Presence of an extensive restoration Tooth mobility Swelling or discoloration Pulp exposure

Challenges 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 Tests Percussion Palpation Thermal Electrical Radiographs

1. Percussion tests Used to determine whether the inflammatory process has extended into the periapical tissues Completed by the dentist tapping on the incisal or occlusal surface of the tooth in question with the end of the mouth mirror handle held parallel to the long axis of the tooth

2. Palpation tests Used to determine whether the inflammatory process has extended into the periapical tissues The dentist applies firm pressure to the mucosa above the apex of the root

3. Thermal sensitivity Necrotic pulp will not respond to cold or hot Cold test Ice, dry ice, or ethyl chloride used to determine the response of a tooth to cold Heat test Piece of gutta-percha or instrument handle heated and applied to the facial surface of the tooth

Evaluation of thermal test results 4 distinct responses: No response non-vital pulp or false negative Mild response normal Strong but brief reversible Strong but lingering irreversible

Causes of false positives/negative Calcified canals Immature apex – usually seen in young patients Trauma Premedication of the patient – pulp sedated

Delivers a small electrical stimulus to the pulp 4. Electric pulp testing Delivers a small electrical stimulus to the pulp Factors that may influence readings: Teeth with extensive restorations Teeth with more than one canal Dying pulp can produce a variety of responses Moisture on the tooth during testing Batteries in the tester may be weak

Placement of a pulp tester.

5. Radiographs Pre-operative radiograph Invaluable diagnostic tool Periapical radiolucency Widening of PDL Deep caries Resorption Pulp stones Large restorations Root fractures

Requirements of Endodontic Films Show 4-5 mm beyond the apex of the tooth and the surrounding bone or pathologic condition. Present an accurate image of the tooth without elongation or fore-shortening. Exhibit good contrast so all pertinent structures are readily identifiable.

Quality radiograph in endodontics.

Diagnostic Conclusions Normal pulp Pulpitis

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

Pulpitis The pulp tissues have become inflamed Can be either: Acute – inflammation of the periapical area – usually quite painful Chronic Continuation of acute stage or low grade infection

Acute Pulpitis mainly occurs in children teeth and adolescent pain is more pronounced than in chronic

Symptoms and Signs of acute pulpitis The pain not localized in the affected tooth is constant and throbbing worse by reclining or lying down The tooth becomes painful with hot or cold stimuli The pain may be sharp and stabbing Change of color is obvious in the affected tooth swelling of the gum or face in the area of the affected tooth

Forms of acute pulpitis 1. Form of purulent acute where the pulp is totally inflammed 2. Form of gangrenous acute where the pulp begins to die in a less painful manner that can lead into the formation of an abscess

Chronic Pulpitis Reversible Irreversible

Reversible pulpitis The pulp is irritated, and the patient is experiencing pain to thermal stimuli Sharp shooting pain Duration of the pain episode lasts for seconds The tooth pulp can be saved Usually this condition is caused by average caries

Irreversible pulpitis The tooth will display symptoms of lingering pain pain occurs spontaneously or lingers minutes after the stimulus is removed patient may have difficulty locating the tooth from which the pain originates As infection develops and extends through the apical foramen, the tooth becomes exquisitely sensitive to pressure and percussion A periapical abscess elevates the tooth from its socket and feels “high” when the patient bites down

Periradicular abscess An inflammatory reaction to pulpal infection that can be chronic or have rapid onset with pain, tenderness of the tooth to palpation and percussion, pus formation, and swelling of the tissues.

Periodontal abscess An inflammatory reaction frequently caused by bacteria entrapped in the periodontal sulcus for a long time. A patient will experience rapid onset, pain, tenderness to palpation and percussion, pus formation, and swelling. Destruction of the periodontium occurs

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

Pulp fibrosis The decrease of living cells within the pulp causing fibrous tissue to take over the pulpal canal

Necrotic tooth Also referred to as non-vital. Used to describe a pulp that does not respond to sensory stimulus Tooth is usually discoloured

Plan of Treatment Depends widely on the diagnosis

Simple plan of treatment Visit 1: Medical history History of the tooth Access cavity Place rubberdam Extirpation + irrigation with sodium hypochlorite Placed intra-canal medication (calcium hydroxide) Place cotton pellet Placed temporary restoration (IRM/Kalzinol)

Visit 2: Working length determination Debridement using the hybrid technique Irrigation Placed intra-canal medication (calcium hydroxide) Place cotton pellet Placed temporary restoration (IRM/Kalzinol)

Visit 3: Obturation of the canal using lateral condensation Placed temporary/permanent restoration (IRM/Kalzinol)

Referral To appropriate discipline

Remember Access cavity shapes: Always use rubberdam Anterior – inverted triangle Premolars – round Molars – rhomboid Always use rubberdam Never to use Cavit as a temporary restoration Always place an intra-canal medication….calcium hydroxide!!! Always use RC Prep or Glyde when filing

Contraindications for RCT Caries extending beyond bone level Rubberdam cannot be placed Crown of tooth cannot be restored in restorative dentistry nor prosthodontics Patient is physically/mentally handicapped and therefore cannot follow OH instructions Putrid OH Unmotivated patient Severe root resorption Vertical root fractures Cost factor

Inter & cross-departmental diagnosis Mobile teeth Teeth associated with severe periodontal problems Confusion between TMJ dysfunctional symptoms and RCT pain Many decayed teeth Sclerosed canal due to trauma Uncertainty of prognosis related to abscess, severe caries, facial swelling, cellulites, and medical condition of patient

Referral to post-grad clinics Extensive internal or external root resorption Severely curved, narrow, tortuous canals Full-mouth rehabilitation required Multiple exposures due to attrition/abrasion Problems with occlusion causing the need for 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 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.

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.

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

Chronic pulpitis chronic pulpitis with a closed pulp chamber chronic ulcered pulpitis hyperplastic pulpitis residual pulpitis retrograde 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 ---deep periodontal pocket ---percussion: (+~++) ---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.

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