dx of pulpal n apical dis. nice

8/9/2019 Dx of Pulpal n Apical Dis. NICE

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Pulpal and periapical diseasePulpal and periapical disease Normal conditionsNormal conditions

A normal tooth isA normal tooth is (a)(a) asymptomatic andasymptomatic and

exhibits aexhibits a (b)(b) mild to moderate transientmild to moderate transient

response to thermal and electric pulpal stimuli;response to thermal and electric pulpal stimuli;

andand (c)(c) the response subsides almostthe response subsides almost

immediately when such stimuli are removed.immediately when such stimuli are removed.

(d)(d) The tooth and its attachment apparatus doThe tooth and its attachment apparatus do

not cause a painful response when percussednot cause a painful response when percussedand palpated.and palpated.



What is pulpal, or periapicalWhat is pulpal, or periapical disease?disease?

The disorders involved in pulp, orThe disorders involved in pulp, or

periapical tissuesperiapical tissues



The classifications of pulpalThe classifications of pulpal

diseasedisease R eversible pulpitisR eversible pulpitis

The pulp is inflamed to the extent that thermal stimuliThe pulp is inflamed to the extent that thermal stimulicause a quick, sharp, hypersensitive response thatcause a quick, sharp, hypersensitive response thatsubsides as soon as the stimulus is removed.subsides as soon as the stimulus is removed.

R eversible pulpitis is not a disease but merely aR eversible pulpitis is not a disease but merely asymptom. If the cause is removed, the pulp shouldsymptom. If the cause is removed, the pulp shouldrevert to an uninflamed state and the symptom shouldrevert to an uninflamed state and the symptom shouldsubside. Conversely, if the cause remains, the symptomsubside. Conversely, if the cause remains, the symptommay persist, and the inflammation may become moremay persist, and the inflammation may become morewidespread, and eventually, leading to an irreversiblewidespread, and eventually, leading to an irreversiblepulpitis.pulpitis.

CausesCauses: any irritant that can affect the pulp may cause: any irritant that can affect the pulp may causereversible pulpitis such as caries, thermal, deepreversible pulpitis such as caries, thermal, deepperiodontal scaling and root planing.periodontal scaling and root planing.



Distinguishing reversible pulpitis from theDistinguishing reversible pulpitis from theirreversible:irreversible:

1.1. A sharp painful response to thermal stimulation.A sharp painful response to thermal stimulation.

2.2. Spontaneous pain.Spontaneous pain.

Treatment choice:Treatment choice:

Sedative dressing, or called temporarySedative dressing, or called temporaryrestoration with sedative package, such as zincrestoration with sedative package, such as zincoxide.oxide.



Irreversible pulpitisIrreversible pulpitis

An irreversible pulpitis may be acute,An irreversible pulpitis may be acute,

subacute, or chronic, and it may be partialsubacute, or chronic, and it may be partial

and total. Clinically, acute one isand total. Clinically, acute one is

symptomatic, whereas the chronic issymptomatic, whereas the chronic is

asymptomatic. At this stage, theasymptomatic. At this stage, the dynamic dynamic

changes in the pulp are always occurring.changes in the pulp are always occurring.



Symptomatic irreversible pulpitisSymptomatic irreversible pulpitis

This type of pulpitis is characterized by This type of pulpitis is characterized by

spontaneous intermittent or continuousspontaneous intermittent or continuous

paroxysms of pain.paroxysms of pain.

The pain may be caused by sudden temperatureThe pain may be caused by sudden temperature

changes, which is prolonged.changes, which is prolonged.

The pain caused by cold stimulation can beThe pain caused by cold stimulation can be

relieved by heat, and similarly, the pain caused by relieved by heat, and similarly, the pain caused by

heat can be relieved by cold.heat can be relieved by cold.



There may even be a painful responseThere may even be a painful responseto both cold and heat stimulation too.to both cold and heat stimulation too.

The pain also can be caused by aThe pain also can be caused by a

change in posture.change in posture.

The pain may be localized or referredThe pain may be localized or referred(e.g. referred from mandibular molars(e.g. referred from mandibular molars

toward the ear or up to the temporal area.)toward the ear or up to the temporal area.)

In the advanced stage, a slight thickeningIn the advanced stage, a slight thickening

in the periodontal ligament may bein the periodontal ligament may bepresented through a radiography.presented through a radiography.



A symptomatic irreversible pulpitisA symptomatic irreversible pulpitis

can be diagnosed by a thoroughcan be diagnosed by a thorough

dental history, visual examination,dental history, visual examination,

thermal tests and radiography.thermal tests and radiography.



Asymptomatic irreversible pulpitisAsymptomatic irreversible pulpitis

This type of irreversible pulpitis isThis type of irreversible pulpitis is

asymptomatic because the inflammatoryasymptomatic because the inflammatory

exudate are quickly vented.exudate are quickly vented.It can develop by the conversion of aIt can develop by the conversion of a

symptomatic one into a quiescent state.symptomatic one into a quiescent state.

It also can caused by long and lowIt also can caused by long and low--grade pulpgrade pulp

irritant (carious lesions), traumatic injury.irritant (carious lesions), traumatic injury.



There are three types of asymptomaticThere are three types of asymptomaticpulpitispulpitis

1.1. Hyperplastic pulpitisHyperplastic pulpitisClinically, it is a reddish cauliflowerClinically, it is a reddish cauliflower--like overgrowthlike overgrowth

of pulp tissue through and around a cariousof pulp tissue through and around a carious

exposure. It is characteristically found in youngexposure. It is characteristically found in young

people since the generous vascularity of the pulp.people since the generous vascularity of the pulp.

2.2. Internal resorptionInternal resorptionIt is a resorption of the dentine from the pulpIt is a resorption of the dentine from the pulp

outward, which is often caused by trauma or pulpoutward, which is often caused by trauma or pulp

capping. It is usually can be diagnosed bycapping. It is usually can be diagnosed by

radiography.radiography.

3.3. Canal calcificationCanal calcificationA large amounts of reparative dentine over depositA large amounts of reparative dentine over deposit

Throughout the canal system, which is caused byThroughout the canal system, which is caused by

periodontal therapy, abrasion, trauma etc.periodontal therapy, abrasion, trauma etc.



NecrosisNecrosis

1.1. Death of pulp, may result form an untreatedDeath of pulp, may result form an untreated

irreversible pulpitis or may occur immediatelyirreversible pulpitis or may occur immediately

after a traumatic injury that disrupts the bloodafter a traumatic injury that disrupts the blood

supply to the pulp.supply to the pulp.2.2. Necrosis may be partial or total, and the partialNecrosis may be partial or total, and the partial

may exhibit some of the symptoms of anmay exhibit some of the symptoms of an

irreversible pulpitis.irreversible pulpitis.

3.3. Occasionally with anterior teeth the crown willOccasionally with anterior teeth the crown willdarken.darken.



Classification of periapical diseaseClassification of periapical disease

Acute apical periodontitisAcute apical periodontitis

It describes inflammation around the apex.It describes inflammation around the apex.

The tooth with it may exquisitely tender toThe tooth with it may exquisitely tender topercussion.percussion.

The tooth may be cariousThe tooth may be carious

R adiographically the apical periodontal ligamentR adiographically the apical periodontal ligament

may appear slightly widened or normal.may appear slightly widened or normal.



Causes:Causes:

Extension of pulpal disease into the periapicalExtension of pulpal disease into the periapical

tissue.tissue.

Endodontic procedures such as canal fillingEndodontic procedures such as canal filling

beyondbeyond

the apical foramen.the apical foramen.

Occlusal trauma from a high restoration or fromOcclusal trauma from a high restoration or from

chronic bruxism.chronic bruxism.



Acute apical abscessAcute apical abscess

It implies a painful, purulent exudate aroundIt implies a painful, purulent exudate around

the apex.the apex.

R apid onset of slight to severe swelling, pain,R apid onset of slight to severe swelling, pain,and pain to percussion, and possible mobility.and pain to percussion, and possible mobility.

The distinguishing acute apical abscess fromThe distinguishing acute apical abscess from

the lateral periodontal abscess and from thethe lateral periodontal abscess and from the

phoenix abscessphoenix abscess



For periodontal abscessFor periodontal abscess

Thermal and electric pulp testing indicateThermal and electric pulp testing indicate

the pulp vital; there is a periodontalthe pulp vital; there is a periodontal

pocket; the tooth may be normal.pocket; the tooth may be normal.For the phoenix abscessFor the phoenix abscess

All symptoms of acute apical abscess plusAll symptoms of acute apical abscess plus

apical radiolucency around the apex of apical radiolucency around the apex of

the tooth.the tooth.



Chronic apical periodontitisChronic apical periodontitis

1.1. Chronic apical periodontitis implies longChronic apical periodontitis implies long--standing asymptomatic inflammation aroundstanding asymptomatic inflammation aroundthe apex. Although chronic apicalthe apex. Although chronic apicalperiodontitis tends to be asymptomatic, thereperiodontitis tends to be asymptomatic, theremay be occasional slight tenderness tomay be occasional slight tenderness to

palpation and percussion.palpation and percussion.2.2. Only biopsy and microscopy examination canOnly biopsy and microscopy examination can

reveal whether these apical lesions are dentalreveal whether these apical lesions are dentalgranulomas, abscesses, or cysts.granulomas, abscesses, or cysts.

3.3. Diagnosis is confirmed by the presence of aDiagnosis is confirmed by the presence of aradiolucency that may be either diffuse orradiolucency that may be either diffuse orwellwell--circumscribed, the absence of pulpcircumscribed, the absence of pulpvitality, and a sinus tract.vitality, and a sinus tract.



Phoenix abscessPhoenix abscessA phoenix abscess is a chronic apicalA phoenix abscess is a chronic apical

periodontitis that suddenly becomesperiodontitis that suddenly becomes

symptomaticsymptomatic

The symptoms are identical to those of anThe symptoms are identical to those of an

acute apical abscess, the man differenceacute apical abscess, the man difference

being that the phoenix abscess isbeing that the phoenix abscess is

preceded by a chronic conditionpreceded by a chronic condition



Periapical osteosclerosisPeriapical osteosclerosis

Periapical osteosclerosis is excessive bonePeriapical osteosclerosis is excessive bone

mineralization around the apex caused bymineralization around the apex caused bylowlow--grade, relatively asymptomatic,grade, relatively asymptomatic,

chronic pulpal inflammationchronic pulpal inflammation

which is most commonly found in young peoplewhich is most commonly found in young people



CausesCauses

Although many factors can cause theAlthough many factors can cause theendodontitis which further develop into apicalendodontitis which further develop into apicalperiodontitis, the bacteria are the mostperiodontitis, the bacteria are the mostcommon one.common one.

The factors include:The factors include:

1.1. BacteriaBacteria2.2. TraumaTrauma

3.3. ThermalThermal

4.4. Static electricityStatic electricity

5.5. LaserLaser

6.6. Filling materialsFilling materials

7.7. Etch or adhesive agentsEtch or adhesive agents

8.8. Drugs for toilet the cavityDrugs for toilet the cavity

9.9. Immunological aspectImmunological aspect



Treatment planingTreatment planing

Once the tooth has been confirmed asOnce the tooth has been confirmed as

irreversible pulpitis or any of apical diseases,irreversible pulpitis or any of apical diseases,the endodontic treatment must be done.the endodontic treatment must be done.

Before you decide to do the endodonticBefore you decide to do the endodontic

treatment you need to consider follows:treatment you need to consider follows:



1.1. Physical evaluationPhysical evaluationit mainly concerned about systemic conditionsit mainly concerned about systemic conditions(diseases) such as cardiovascular diseases,(diseases) such as cardiovascular diseases,bleeding disorders, diabetes, cancer, AIDS,bleeding disorders, diabetes, cancer, AIDS,pregnancy, allergies, steroid therapy, infectiouspregnancy, allergies, steroid therapy, infectious

diseases etc.diseases etc.

2.2. Psychological evaluationPsychological evaluationA patient who shows no incentive (motivation)A patient who shows no incentive (motivation)to maintain good oral hygiene or one whoto maintain good oral hygiene or one who

constantly misses appointments may not be aconstantly misses appointments may not be agood candidate for endodontic therapy.good candidate for endodontic therapy.



3.3. Evaluation of toothEvaluation of tooth

MorphologyMorphology

Unusual lengthUnusual length Unusual shapesUnusual shapes

Unusual numbers (canal or roots)Unusual numbers (canal or roots)

R esorptionsR esorptions

CalcificationsCalcifications

Previous treatmentPrevious treatment Canal blockageCanal blockage

LedgeLedge

perforationsperforations

Location of toothLocation of tooth

AccessibilityAccessibility Proximity to other structuresProximity to other structures

R estorabilityR estorability

Periodontal statusPeriodontal status



Canal shape:Canal shape: an open apex requires apical losurean open apex requires apical losure

techniques before obturationtechniques before obturation



Proximity to other structuresProximity to other structures

mental foramenmental foramen



Maxillary sinusMaxillary sinus



RestorabilityRestorabilitydecay into the furcation may render a tooth untreatable.decay into the furcation may render a tooth untreatable.



4. Treatment planning4. Treatment planning

general process and sequence:general process and sequence:

Management of acute pulp or periodontal pain.Management of acute pulp or periodontal pain.

Oral surgery for extraction of unsalvageableOral surgery for extraction of unsalvageableteeth.teeth.

Caries control of deep lesions that mayCaries control of deep lesions that may

threaten the pulp.threaten the pulp.

Periodontal procedures to manage soft tissue.Periodontal procedures to manage soft tissue.

Endodontic procedures for asymptomatic teethEndodontic procedures for asymptomatic teethwith necrotic pulps and surgical treatment orwith necrotic pulps and surgical treatment or

rere--treatment of failing root canals.treatment of failing root canals. R estorative and prosthetic procedures.R estorative and prosthetic procedures.

OneOne--appointment root canal therapyappointment root canal therapy



What do we know now?

What do we know now?

What is pulpitis or apical periodontitis?What is pulpitis or apical periodontitis?

What are the symptoms for these twoWhat are the symptoms for these two

diseases?diseases? The significance of clinical classifications?The significance of clinical classifications?

What need to be considered when you areWhat need to be considered when you areabout doing endodontic treatment?about doing endodontic treatment?

dx of pulpal n apical dis. nice

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