1. 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.

2. 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

3. 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

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

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

6. 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?

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

8. 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.

9. Diagnostic Tests
Percussion
Palpation
Thermal
Electrical
Radiographs

10. 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

11. 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

12. 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

13. 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

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

16. 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

17. Placement of a pulp tester.

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

20. 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.

21. Quality radiograph in endodontics.

22. Diagnostic Conclusions
Normal pulp
Pulpitis

23. 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

24. 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

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

26. 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

28. 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

29. Chronic Pulpitis
Reversible
Irreversible

30. 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

31. 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

32. 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.

34. 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

36. 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

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

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

39. Plan of Treatment
Depends widely on the diagnosis

40. 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)

41. 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)

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

43. Referral
To appropriate discipline

44. 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

45. 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

46. 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

47. 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

48. PULPAL DISEASE Classified as: Reversible pulpitis
Irreversible pulpitis
Necrotic pulp

49. Pulpal Disease
Reversible
Pulpitis

50. 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.

51. 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)

52. 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

53. 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.

54. Pulpal Disease
Irreversible
Pulpitis

55. 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.

56. 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

57. 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

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

59. Pulpal Disease
Necrotic
Pulp

60. 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).

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

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

63. 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)

64. 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

65. Chronic pulpitis chronic pulpitis with a closed pulp chamber
chronic ulcered pulpitis
hyperplastic pulpitis
residual pulpitis
retrograde pulpitis

66. 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

67. 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: (+)

68. hyperplastic pulpitis
---typical complain, bleeding when chewing
---pulp polyp
---tartar in the same side
---in young people
---distinguish from the other polyp

69. 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

70. retrograde pulpitis ---deep periodontal pocket ---percussion: (+~++)
---pulpitis and periodontitis
---deep periodontal pocket
---percussion: (+~++)
---pulp test: difference
---radiogralph：radiolucency around
the root and furcation

71. 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.

72. 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

75. 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)

76. Differential diagnosis
Pulp necrosis
( same symptoms but pain is only triggered on hot irritant, also a continuity between cavity and pulp exists )

77. 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.

78. Questions????