pulpal & periradicular diseases & their diagnosis

PULPAL & PERIRADICULAR DISEASES

DISEASES OF PULPAL & PERIRADICULAR TISSUE1ADITI SINGH P.G DEPT. OF PEDODONTICSSDCH

THE HERO----PULPTHE PROBLEM---DISEASES OF PULP SIDEKICKS----PERIRADICULAR TISSUETHE PROBLEM PART 2 ---DISEASES OF PERIRADICULAR TISSUETHE STORY---DIAGNOSIS OF PULP DISEASESINTERVAL --- CONCLUSIONCONTENTS2

THE HERO3

The dental pulp is a delicate soft connective tissue interspersed with tiny blood vesels,lymphatics ,myelinated & unmyelinated nerves & undifferentiated connective tissue cells that supports the dentin.PULP

Chandra SB,Gopikrishna V;Grossmans Endodontic Practice 12 Ed; 2010;Wolters Kluver 4

The problem5

CLASSIFICATIONS.Abbott, PV,Yu C;A clinical classification of the status of the pulp and theroot canal system;Australian Dental Journal Supplement 2007;52:(1 Suppl):S17-S31WHOAAE glossaryNormal pulp not mentioned Normal pulp not mentioned Pulpitis : Initial (hyperaemiaAcute suppurativeChronic (ulcerative / hyperplastic)Other unspecified pulpitis

Pulpitis : ReversibleIrreversiblePulpnecrosisPulpNecrosisPulp degeneration :Denticles Calcification StonesAbnormal hard tissue formation in pulp Secondary or irregular dentin

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WeineIngleCohen & BurnsNormal pulp not mentionedHealthy pulpNormal not mentioned Pulpitis Hyperalgesia Hypersensitive dentin Hyperemia Painful pulpitis (Acute, Chronic) Nonpainful pulpitis (Chronic ulcerative , Chronic pulpitis, Chronic hyperplasticPulpitis:Hyper-reactive pulpalgiaHypersensitivityHyperaemiaAcute pulpalgiaChronic pulpalgiaHyperplastic pulposisPulpitis:ReversibleIrreversible Asymptomatic Hyperplastic Internal resorption Canal calcification Symptomatic Pulp NecrosisPulp necrosis Necrosis (Partial or complete)Pulp DegenerationPulp degenerationInternal resorptionInternal resorption

Abbott, PV,Yu C;A clinical classification of the status of the pulp and theroot canal system;Australian Dental Journal Supplement 2007;52:(1 Suppl):S17-S317

THE CLASSIFICATION Chandra SB,Gopikrishna V;Grossmans Endodontic Practice 12 Ed; 2010;Wolters Kluver Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.8

Its not a disease but a symptom mild to moderate inflammatory condition of pulp caused by noxious stimuli pulp is capable of returning to un-inflammed state following removal of stimuli

REVERSIBLE PULPITIS

Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.Chandra SB,Gopikrishna V;Grossmans Endodontic Practice 12 Ed; 2010;Wolters Kluver 9

Causes

agent capable of injuring pulp like:

trauma disturbed occlusal relationship thermal shockCarious lesion


Clinical Features

sharp pain lasting for a moment

often brought on by cold than hot food or beverages and by cold air


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Clinical Features

does not continue when the cause has been removed

tooth responds to electric pulp testing at lower current


Treatment Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. Removal of noxious stimulus

Prevention

Early filling of carious lesion

Periodic care

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earliest form

also known as pulp hyperemia

excessive accumulation of blood within pulp tissue

leads to vascular congestion

FOCAL REVERSIBLE PULPITIS

Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.14

Clinical Features

sensitive to thermal changes

particularly to cold

application of ice or cold fluids to tooth result in pain


Clinical Features

disappears upon removal of thermal irritant or restoration of normal temperature

responds to electrical test stimulant at lower level of current


Clinical Features

indicates lower pain threshold than that of adjacent normal teeth


Clinical Features

teeth show:

deep carious lesion

large metallic restoration

restoration with defective marginsMANAGEMENT : Removal of noxious stimulus before the pulp is severely damaged.


persistent inflammatory condition of pulp

may be symptomatic or asymptomatic

caused by noxious stimulus

IRREVERSIBLE PULPITIS


Causes

bacterial involvement of pulp through caries

chemical

thermal

mechanical injury

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Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.

Clinical Features

Early Stage

paroxysm of pain caused by:

sudden temperature changes like cold, sweet, acid foodstuffs.


Clinical Features

Early Stage

pain often continues when cause has been removed

may come and go spontaneously


Clinical Features

Early Stage

pain

sharp piercing shooting generally severe


Clinical Features

Early Stage

pain

bending overexacerbates pain which lying downis due to change in change of positionintrapulpal pressure


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Clinical Features

Late Stage

pain

more severe as if tooth is under throbbing constant pressure


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Clinical FeaturesLate Stage

pain

patient is often awake at night due to pain

increased by heat and sometimes relieved by cold, although continued application of cold may intensify pain MANAGEMENT : Endodontic therapy


Reversible PulpitisIrreversible Pulpitis pain is generally traceable to a stimulus cold water air

more severe lasts longer pain may come without any apparent stimulus

REVERSIBLE Vs IRREVERSIBLE PULPITIS


extensive acute inflammation of pulp

frequent sequel of focal reversible pulpitis

ACUTE PULPITIS


Causes

tooth with large carious lesion

defective restoration where there has been recurrent caries

pulp exposure due to faulty cavity preparation

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Clinical Features

severe pain is elicited by thermal changes

pain persists even after thermal stimulus disappears or has been removed


Clinical Features

may be continuous

intensity may be increased when patient lies down

application of heat may may cause acute exacerbation of pain


Clinical Features

tooth reacts to electric pulp vitality tester at a lower level of current than adjacent normal teeth


pressure increases because of lack of escape of inflammatory exudate

rapid spread of inflammation through pulp with pain + necrosis

Management : endodontic therapy


may develop with or without episodes of acute pulpitis

many pulps under large carious cavities die painlessly

1st indication is then development of periapical periodontitis, either with pain or seen by chance in radiograph

CHRONIC PULPITISCohen S,Burns RC; Pathways of Pulp; 6Ed,2008.34

Clinical Features

dull aching type

more often intermittent than continuous MANAGEMENT : endodontic therapy


also called as pulp polyp or pulpitis aperta

essentially an excessive exuberant proliferation of chronically inflamed dental pulp tissue

CHRONIC HYPERPLASTIC PULPITIS


pulpal inflammation due to an extensive carious exposure of a young pulp

development of granulation tissue

covered at times by epithelium

resulting from long standing low grade infection


Causes

slow progressive exposure of pulp

bacterial infection


Clinical Features

most commonly involved are deciduous molars + 1st permanent molar

excellent blood supply large root opening


Clinical Features

asymptomatic

seen only in teeth of children + young adults


Clinical Features

polypoid tissue appears fleshy reddish pulpal mass filling most of pulp chamber or cavity or even extend beyond confines of tooth


Clinical Features

sometimes, if mass is large enough interferes with closure of mouth


Clinical Features

may cause discomfort during mastication due to pressure of food bolus


Clinical Features tissue easily bleeds because of rich network of blood vessels

tooth may or may not respond at all to thermal test


PULP POLYP Vs GINGIVAL POLYPPULP POLYP1.Soft edematous more reddish in appearance

2.Friable 3. On passing a probe around the polyp we can trace its origin within the tooth 4.Endodontic therapy or extraction in case of hopeless prognosisGINGIVAL POLYP1.Comparitively firm with color similar to that of adjacent gingiva ( unless secondarily traumatized or inflamed)2.Non friable3. On passing a probe around the polyp we can trace its origin around or adjacent to the tooth 4.Remove the etiology for eg. calculus around the tooth 45

elimination of polypoid tissue followed by extirpation of pulp

hyperplastic tissue bleeding can be controlled by pressure

extraction of tooth can also be done

MANAGEMENT Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.46

death of pulp

may be partial or total depending on whether part or the entire pulp is involved

PULP NECROSISCohen S,Burns RC; Pathways of Pulp; 6Ed,2008.47

Causes

sequelae of inflammation

can also occur following trauma

pulp is destroyed before an inflammatory reaction


Types

(1) Coagulation Necrosis

(2) Liquefaction Necrosis


Types


soluble portion of tissue is precipitated or converted into a solid material


Types


tissue is converted into tissue mass consisting chiefly of coagulated

proteins fats water


Types

(2) Liquefaction Necrosis

results when proteolytic enzymes convert the tissue into softened mass liquid or amorphous debris


Clinical Features

no painful symptoms

discoloration of tooth

1st indication that the pulp is dead


Clinical Features

history of pain lasting from a few minutes to a few hours followed by complete + sudden cessation of pain

MANAGEMENT : Endodontic therapy


1.A mixture of the signs and symptoms of both pulpitis and necrosis with infection.2.mild with intermittent painful episodes over many weeks or months. 3.Pulp sensitivity test results are mixed and frequently inconclusive or inconsistent with the patients description of symptoms. 4.Teeth with necrobiosis may also have apical periodontitis with radiographic evidence of a widened periodontal ligament space, which may be unexpected because the patient has reported sensitivity to hot and/or cold stimuli.NECROBIOSISAbbott, PV,Yu C;A clinical classification of the status of the pulp and theroot canal system;Australian Dental Journal Supplement 2007;52:(1 Suppl):S17-S3155

Incomplete fracture of a vital posterior tooth thatinvolves the dentine and occasionally extends intothe pulp.

CRACKED TOOTH SYNDROME (Cameron 1964)Lynch CD,McConnell RJ; The Cracked Tooth Syndrome; J Can Dent Assoc 2002; 68(8):470-5

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Etiology..

Lynch CD,McConnell RJ; The Cracked Tooth Syndrome; J Can Dent Assoc 2002; 68(8):470-557

TreatmentLynch CD,McConnell RJ; The Cracked Tooth Syndrome; J Can Dent Assoc 2002; 68(8):470-5

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Barodontalgia is a symptom rather than a pathological conditionIts defined as an oral (dental or nondental) pain caused by achange in barometric pressure in an otherwiseasymptomatic organ.(Zadik Y )CLASSIFICATION : (FDI)

BARODONTALGIA

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Cementing of fixed prosthesis with resin cements forpatients Endodontically treated teeth that have been open for endodontic treatment and temporarily sealed have been report to be explode on deep sea diving known as Odontocrexis, full porcelain crowns have been reported to shatter at a dive of 65 ft, hence meticulous oral health advice should be given to the divers, all carious lesions should be restored, all ill fitting crowns should be replaced with a good cementing medium, active periodontal lesion treatment and completion of endodontic treatment should be done. Also removable dentures are not recommended rather a FPD or an implant is indicated.MANAGEMENTGaur TK, Shrivastava: Barodontalgia: A Clinical Entity J Oral Health Comm Dent 2012;6(1)18-2060

Barotrauma in flight Vs in divingIn flight the theoretically possible pressure changes range from 1 atm (at ground level) to 0 atm (at outer space)Possible mechanism of barotrauma1.Direct ischaemia resulting frominflammation itself2. Indirect ischaemia resulting fromintra-pulpal increased pressure asa result of vasodilatation and fluiddiffusion to the tissue3. The result of intra-pulpal gasexpansion.The gas is a by-productof acids, bases, and enzymes in theinflamed tissue4. The result of gas leakage throughthe vessels because of reduced gas solubilityIn diving the changes are more significant, since eachdescent of 10 meters (32.8 feet) elevates the pressureby 1 atm.The most common way for air from the pressurized tanks to enter a tooth is by being forced in through carious lesions or defective marginsAs atmospheric pressure decreases during ascent, trapped gases may expand and enter dentin tubules, thereby stimulating nociceptors in the pulp or causing the movement of pulp chamber contents through the apex of the tooth, also causing pain61

THE SIDEKICKS..62

The periradicular tissue comprises ofsurroundin Alveolar bone, periodontal ligament & cementum.PERIRADICULAR TISSUE


CLASSIFICATION..Chandra SB,Gopikrishna V;Grossmans Endodontic Practice 12 Ed; 2010;Wolters Kluver

64

K 04.4 : Acute apical periodontitisK 04.5 : Chronic apical periodontitis (apical granuloma)K 04.6 : Periapical abscess with sinusK 04.60: periapical abscess with sinus to maxillary antrumK 04.61 : periapical abscess with sinus to nasal cavityK 04.62 : periapical abscess with sinus to oral cavityK 04.63 : periapical abscess with sinus to skinK 04.7 : periapical abscess without sinusK 04.8 : radicular cyst K 04.80 : Apical and lateral cystK 04.81 : Residual cystK 04.82 : Inflammatory paradental cystWHO CLASSIFICATIONChandra SB,Gopikrishna V;Grossmans Endodontic Practice 12 Ed; 2010;Wolters Kluver 65

PERIAPICAL PATHOLOGYSymptomatic apical periodontitis (acute apical periodontitis): a painful response to biting and percussion. It may or may not be associated with an apical radiolucent area.

Asymptomatic apical periodontitis (chronic apical periodontitis):It appears as an apical radiolucent area, and does not produce clinical symptomsCohen S,Burns RC; Pathways of Pulp; 6Ed,2008.66

ACUTE Vs CHRONIC gradual onset, little or no discomfort, and the intermittent discharge of pus through an associated sinus tract.

Acute apical periodontitis

rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation, and eventual swelling of associated tissues

Chronic apical (periapical) periodontitisCohen S,Burns RC; Pathways of Pulp; 6Ed,2008.67

An acute apical abscess may result when large numbers of bacteria get past the apex and elicit a severe inflammatory response.

.This response is acute, the predominant cell being the polymorphonuclear leukocyte. With the release of PMN lysosomal enzymes into the tissue space and the concomitant tissue degradation, an abscess forms

An abscess is defined as a localized collection of pus which, microscopically, is composed of dead cells, debris, PMNs, andmacrophages.

ACUTE APICAL ABSCESSCohen S,Burns RC; Pathways of Pulp; 6Ed,2008.68

CLINICAL MANIFESTATIONvarying degrees of swelling occur, with pain. The patient complains of a feeling that the tooth is elevated out of the socket. Elevated temperature and malaise may follow. The body responds to this insult by trying to isolate the abscess and/or establish drainage either intraorally or extraorally. If drainage is not effective, the abscess may spread into fascial planes or spaces of the head and neck.PHONIX ABSCESSIf a periapical radiolucency is present and an acute inflammatory response is superimposed on this preexisting chronic lesion it is termed a phoenix abscess.ACUTE APICAL ABSCESSCohen S,Burns RC; Pathways of Pulp; 6Ed,2008.69

Acute osteomyelitis can arise directly from an endodontic infection. Live bacteria are past the apex and now are multiplying in the marrow spaces and soft tissue of the bone. Osteomyelitis may be a serious progression of periapical infection that results in diffuse spread through the medullary spaces, ultimately leading to necrosis of bone. Acute osteomyelitis may be localized or spread throughout large areas of boneACUTE OSTEOMYELITISCohen S,Burns RC; Pathways of Pulp; 6Ed,2008.70

CLINICAL MANIFESTATIONThe patient usually has severe pain, an elevated temperature, and palpable lymph nodes. Although the teeth are loose and sore in the early stages, there may be no swelling, and radiographic changes are difficult to detectThere may or may not be pus formationIf untreated, the acute form may progress to chronic disease.Clinically, chronic suppurative osteomyelitis is the same as acute except the symptoms are milder and radiographically diffuse bone resorption is evident.ACUTE OSTEOMYELITISCohen S,Burns RC; Pathways of Pulp; 6Ed,2008.71

TREATMENT Hyperbaric oxygenEndodontic therapy or extraction of the carious toothMore surgical treatment may be requiredAggressive antibiotic therapy to nail the causative bacteriaACUTE OSTEOMYELITISCohen S,Burns RC; Pathways of Pulp; 6Ed,2008.72

An apical lesion that has established drainage through a sinus tract is termed suppurative inflammationCLINICAL MANIFESTATIONThe patient may complain of a "gum boil" or a badtaste in the mouth. Pus may be expressed through the opening by gentle pressure. A radiograph should be exposed with a gutta-percha probe inserted into the tract to determine the cause of the lesion.SUPPURATIVE APICAL PERIODONTITISCohen S,Burns RC; Pathways of Pulp; 6Ed,2008.73

A foreign body response may occur to many types of substances.The reaction can be acute and/or chronicThese lesions may or may not be symptomatic. The cause is now beyond the apex, so surgery may be necessary to remove the foreign material and effect healingFOREIGN BODY REACTIONCohen S,Burns RC; Pathways of Pulp; 6Ed,2008.74

The inflammatory response depends on the quality, duration, and virulence of the irritant. A very low-grade, subclinical response may lead to an increase in the bone density rather than resorption and radiolucency. This lesion may be clinically asymptomatic and radiographically can demonstrate increased trabeculation and opacityIf it is associated with a necrotic or diseased pulp endodontic therapy may lead to healing

Osteosclerosis or condensing osteitis


This is a chronic inflammatory lesion that has epithelium lining the lumen, but the lumen has a direct communication with the root canal system. It is not a true cyst, because a true cyst is a three-dimensional, epithelium-lined cavity with no communication between the lumen and the canal systemThe distinction between a bay and a true cyst is important from the standpoint of healing While bay cyst can be treated with endodontic therapy true cyst requires surgical excision (Vaulderhaug , Bhsskar SN 1971;Mortensen etal 1972)BAY CYST Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.76

Antibioma is a sterile, chronic abscess formed because of incomplete treatment of an infection by using antibiotics without incision and drainage.

It may present with pain, swelling, and tenderness or with mass effect in the form of neuralgic pain.

ANTIBIOMA77

THE STORY78

CASE HISTORYCHIEF COMPLAINTHISTORY OF PRESENT ILLNESSMEDICAL HISTORYDENTAL HISTORYDRUG HISTORY

79

PAINMODE OF ONSET : Spontaneous or provokedFREQUENCY & DURATION : continuous or intermittent QUALITY OF PAIN : Dull aching : pain of bony origin Throbbing or pulsing : Pain of vascular origin Sharp stabbing recurrent : pathology of nerve root complexPOSTURAL CHANGES : Pain increases on bending or lying down indicates pulpal pain

80

TYPE OF PAIN

Momentary pain

Persistent pain

Spontaneous pain

Provoked pain

81

EXTRAORAL EXAMINATIONFacial symmetry

Lymph nodes

TMJ

82

INTRAORAL EXAMINATIONSOFT TISSUSE EXAMINATION

SwellingDiscolorationSinus formationGingival inflammation

83

VISUAL EXAMINATIONMobility in primary tooth may be physiological or pathological WYMANS INDEX : 0:horizontal 2mm & Vertical

84

PERCUSSION : can be checked by applying finger pressure on the tooth or tapping with tip end of handle of the mirror ; if pain then periodontal ligament is inflamed.Lateral percussion is done to check for lateral periodontitis or periodontitis of gingival originApical / vertical percussion is done to check for apical periodontitis

PALPATION : simple test done with finger tips using light pressure to examine tissue consistency & pain response

EXPOSURE SITE : Light red blood that can be arrested easily is associated with inflamed coronal pulp of primary teeth. Deep red blood indicates that inflammation has extended into the root canals of primary teethIngle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc

85

PULP TESTINGThermal Test : Heat Test / Cold Test No Response Mild Moderate response that subsides in 1-2 secStrong Momentary pain that subsides in 1-2 secsModerate to strong pain for several secs. or longerCold tests are most likely to give a positive response in the cervical area compared to the occlusal surface

Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc86

ELECTRIC PULP TESTINGFalse positive response : improper isolation, liquefactive necrosis of pulp,apprehensive patient, electrode contacts with metal restoration or gingivaFalse negative response : recent trauma to tooth,calcification of root canal,immature apex formation,partial necrosis, incomplete circuit formation,Heavy premedications


Jacobson reported that the optimal placement of the probe tip in vitro was the occlusal two-thirds on the labial or buccal surfaces of teeth. Other investigators have reported that the incisal edge was the optimal placement site to achieve the lowest possible threshold for an EPT response. The threshold increased as the probe tip was moved toward the gingival margin.Jacobson JJ. Probe placement during electric pulp-testing procedures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1984;58(2):2427.88

Thermal pulp testing depends on the outward and inward movement of the dentinal fluid, whereas electric pulp testing depends on ionic movement.Because of their distribution, larger diameter than that of C fibres, their conduction speed and their myelin sheath, A-delta fibres are those stimulated in electric pulp testing.C fibres do not respond to electric pulp testing. Because of their high threshold, a stronger electric current is needed to stimulate them.Based on the hydrodynamic effect, outward movement of dentinal fluid caused by the application of cold (contraction of fluid) produces a stronger response in A-delta fibres than inward movement of the fluid caused by the application of heat.Repeated application of cold will reduce the displacement rate of the fluids inside the dentinal tubules, causing a less painful response from the pulp for a short time, which is why the cold test is sometimes refractory.Some pointers.Elmeguid AA Yu DC: Dental Pulp Neurophysiology: Part 1. Clinical andDiagnostic Implications;JCDA;2009;75(1):55-5989

The A-delta fibres are more affected by the reduction of pulpal blood flow than the C fibres because the A-delta fibres cannot function in case of anoxia.An uncontrolled heat test can injure the pulp and release mediators that affect the C fibresA positive percussion test indicates that the inflammation has moved from the pulp to the periodontium, which is rich in proprioceptors, causing this type of localized response

Elmeguid AA Yu DC: Dental Pulp Neurophysiology: Part 1. Clinical andDiagnostic Implications;JCDA;2009;75(1):55-5990

Percussion Testing is most reliable in primary teeth. (C Delta fibres)

Thermal sensitivity Testing & Electrical Pulp Testing are NOT very reliable in primary teeth( A Delta fibres ) because of failure of complete development of Rashkows nerve plexus

Camp JH; Diagnosis Dilemmas in Vital Pulp Therapy: Treatment for the Toothache Is Changing, Especially in Young, Immature Teeth; J Endod 2008;34:S6-S1291

RADIOGRAPHIC INTERPRETATIONPathologic bone resorption.The bone destruction is seen in the furcation area of the tooth. The finding of bone resorption is indicative of widespread pulpal necrosis and nonvitality of the associated tooth.


Pathologic root resorption. Commonly associated with pathologic bone resorption .

Internal/External resorption.It will probably be seen in the root canals and again is evidence of advanced degenerative changes throughout the pulp. Pulp therapy will generally not be successful as the resorptive process is not readily retarded.


Calcific changes. Calcified bodies (known as calcific masses or globules) present in the pulp indicate advanced pulpal degeneration with inflammation spread throughout the coronal portion of the pulp.

Widened periodontal membrane/ligament. A widened PDL is usually indicative of pulpal pathology.


HISTOLOGY Vs RADIOGRAPHY

HISTOLOGIC APPEARANCERADIOGRAPHIC FEATURESIncipient apical periodontitisBone structural changesInitial inflammation with acute featuresBone structural changesChronic inflammationBone demineralisation; lesion area definedGranuloma or cyst formationRadioluscent area; peripheral bony rimLesion with features of exacerbationBone structural changes peropheral to lesion


PERIAPICAL INDEX SCORINGOrstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radiographic assessment of apical periodontitis. Endod Dent Traumatol 1986;2:2034.

96

Normal pulpReversible pulpitisIrreversible pulpitis AsymptomaticIrreversible pulpitis symptomaticPulp necrosissignsnonePatient historyNo h/o spontaneous painNo h/o spontaneous painnoneSpontanoeus painNo pain to severe painCold testQuick mild response to cold which doesnt lingerQuick & sometimes sharp response discomfort does not lingerQuick & sometimes sharp response & discomfort does not lingerExagerrated response to cold with linering painNo responsePercussion sensitivitynegativeNegativeNegativeMay be positiveNo response to exaggerated responseRadiographic findingsnormalnormalCaries present; normal pdl or thickened pdlNormal pdl or thickened pdlNormal periapex to large periapical radioluscency

Zero DT, Zandona AF,Macapagal M,Spolnik KJ; Dental caries & pulpal disease ; Dent Clin N Am ;2011; 55;29-4697

Normal periapexSymptomatic APAsymptomatic APAcute apical abscess Chronic apical abscessPatient historynonePain when bitingnoneExtreme pain on bitingUsually nonevitalitywnlUsually no response to vitalityNo response to vitalityNo responseNo responsepercussionnonepositiveNone to slight positiveNone to slightpalpationnoneMay or may not be positiveWNLpositiveNone to slight with sinus tract presentRadiographic findingsnormalWidenend PDL space or periapical radiolusceucy Periapical radioluscencyWidened PDL space to periapical radioluscecyPeriapical radioluscency

Zero DT, Zandona AF,Macapagal M,Spolnik KJ; Dental caries & pulpal disease ; Dent Clin N Am ;2011; 55;29-4698

Anesthetic testing (Grossman 1978) Source of pain may be identified by giving intraligamentary anesthetic when all other tests fail to isolate the tooth in questionTest Cavity : (Seltzer & Bender 1975) Every tooth is drilled upto the Dentinoenamel junction using slow speed hand piece without water. If sensitivity present then pulp is vital. Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc99

WHATS NEW?100

PhotoplethysmographyPassing of light through the tooth & measuring existing wavelength using galvanometer.Vital pulp will show vascular dilatation on warming it which will be recorded as current on the galvanometer.This is an optical measurement technique that can be used to detect blood volume changes in the microvascular bed of tissue. The basic form of PPG technology requires only a few optoelectronic components: a light source to illuminate the tissue (e.g., skin or tooth) and a photodetector to measure the small variations in light intensity associated with changes in perfusion in the catchment (study) volume.


It is a method independent of a pulsatile circulation. The presence of arterioles rather than arteries in the pulp and its rigid encapsulation by surrounding dentine and enamel make it difficult to detect a pulse in the pulp space. This method measures oxygenation changes in the capillary bed rather than in the supply vessels and hence does not depend on a pulsatile blood flow.Oximetry by spectrophotometer determines the level of oxygen saturation in the pulpal blood supply with a dualwavelength light source (760 and 850 nm).

Dual wavelength spectrometryTyagi SP, Sinha DJ, Verma R, Singh UP. Newvistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90102

Teeth with vital pulps fluoresced normally but the teeth with necrotic or absent pulps do not fluoresce when exposed to ultraviolet light.There are differences in characteristics of healthy dentin and decayed dentin fluorescence spectra at excitations of 405 nm and 440 nm UV lightFluorescence from the pulp are substantially lower than the healthy and decayed dentin fluorescence.FIBREOPTIC FLUORESCENT SPECTROMETRYTyagi SP, Sinha DJ, Verma R, Singh UP. Newvistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90103

Xeroradiography is an electrostatic process which uses an amorphous selenium photoconductor material, vacuum deposited on an aluminum substrate, to form a plate.The key functional steps in the process involve the sensitization of the photoconductor plate in the charging station by depositing a uniform positive charge on its surface with a corona-emitting device called scorotronThe generated latent image is developed through an electrophoretic development process using liquid toner.Soft tissues on xeroradiographic films have well defined outlines that may permit confident evaluation of the soft tissue height and contour. Xeroradiographs provide greater overall soft tissue detail making possible evaluation of its density, texture, and contents. It reveals soft tissues calcifications which are not easily discerned in conventional radiographs.This property may be employed in endodontics to visualized early pulpal calcifications.detailed visualization of lamina dura, bony trabeculae, fine metal nstruments like files, broaches etc, root apices, periodontal ligament spaces

XeroradiographyUdoye C,Jafarzadeh H : ,Xeroradiography: Stagnated after a Promising Beginning? A Historical Review;Eur J Dent 2010;4:95-99)104

TOOTH TEMPERATUREHugeyes Probeye Camera : it can record temperature changes as small as 0.1oC.it requires thermal video system & silicon close up lensHere a color image is produced which indicates arelative difference in temperature in both superficial anddeep areas. Computercontrolled infrared thermographic imaging is another noninvasive method of recording the surface temperature of the body.The use of Huges Probeye 4300 Thermal Video System (Hughes Aircraft Co., Carlsbad, CA) was reported in 1989 by Pogrel et al.[55] and was found to be sensitive enough to measure temperature differences as low as 0.1C.Newer, less cumbersome, and easier to use models is now available.Thermography : recording the infrared radiations emitted from the tooth


Pulse Oximetry uses red and infrared wavelengths in order to transilluminate a tissue and detects absorbance peaks due to pulsatile circulation and uses thisinformation to calculate the pulse rate and oxygen saturation. Beer Lamberts law: the absorption oflight by a solute is related to its concentration at a given wavelength.Pulse Oximetry also uses the characteristics of hemoglobin .i.e in the red and infrared range oxy hemoglobin absorbs more light in the red range than deoxy hemoglobin and vice versa in theinfrared range.Oxygen saturation of Pulp.Avg value : (Pulp) 94% PR : 72/min

PULSE OXIMETER

Tyagi SP, Sinha DJ, Verma R, Singh UP. New vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90.106

LASER DOPPLER FLOWMETRY

Doppler frequency shiftThe fraction of light that is scattered back from the illuminated area is detected & processed to give a signal which is a measure of the blood flow in the dental pulpThe total backscattered light is processed to produce an output signal which is commonly recorded as the concentration and velocity (flux) of cells using an arbitrary term perfusion units (PU), (2.5 volts of blood flow = 250 PU).Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc107

Transillumination (using Fibreoptic light)

Incomplete crack in the tooth (greenstick fractures) Pulp vitality in anterior teeth post trauma.UV Light : 1.Some objects possess the unusual feature of being able to emit light of a higher wavelength when illuminated with UV light. That principle is called fluorescence. 2.Foreman reported that teeth with necrotic pulps and teeth with endodontic treatment did not fluoresce when exposed to UV light while teeth with vital pulps fluoresced normally

Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc

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The device uses a transducer (a crystal containing probe), a coupling agent and software with customized electronic and digital signal processing algorithms.US waves are generated when an alternating current (310 MHz) is applied to the crystal as a consequence of the piezoelectric effect.When the operator moves the probe in the examination area a change is created on the sector plane, thus producing a realtime threedimensional image of that particular space. US has the ability to penetrate hard tissues and in principle can successfully detect discontinuities and pathosis even under existing radioopaque restorations. Because the different biological tissues in the body possess different mechanical and acoustic properties, the US waves at the interface between two tissues with different acoustic impedance undergo the phenomena of reflection and refraction. The echo is the part of the US wave that is reflected back from the tissue interface toward the transducer.USGIngle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc109

When applied to US examination, Color Power Doppler flowmetry allows the presence and direction of the blood flow within the tissue of interest to be observed.The intensity of the Doppler signal is represented by changes in real time on a graph (Doppler) and is also shown in the form of color spots on the gray scale image (color). Positive Doppler shifts are caused by the blood moving toward the transducer and are represented in red, whereas negative Doppler shifts are caused by blood moving in the opposite direction and are represented in blue.ULTRASOUND DOPPLER110

MRIBest resolution of tissue of low inherent contrastNo ionizing radiations involvedDirect multiplanar image is possible without reorienting the patientDisadvantages: Potential hazard due to presence of large ferromagnetic metals in the vicinityLong imaging time The nature of periapical lesions could be determined as well as the presence, absence and/or thickening of the cortical bone. Goto et al. (2007)No artefacts (Eggars et al. 2005) Cotti & Campisi (2004)Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc111

Cholesteric liquid crystalsCholesteric crystals are a type of liquid crystal, i.e. ordered fluids, with a helical structure ordered along the long axis known as chiral nematic liquid crystals.Due to their fluidity these are easily influenced bytemperature or pressure. The pitch of the very structure of the crystal varies when the pressure or temperature are altered thus changing their color heated i.e. they are thermochromic.When applied to the tooth surface, the crystals undergo color changes that were compared with adjacent or contralateralteethInferences : Vital Non Vital blue green Red Red Green Yellow Green Yellow redIngle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc112

3D volume of data is acquired in the course of a single sweep of the scanner, using a simple, direct relationship between sensor and source, which rotate synchronously through 180360 around the patients head. The X-ray beam is cone-shaped (hence the name of the technique) and captures a cylindrical or spherical volume of data, described as the field of view The size of the field of view (FOV) is variable, large volume CBCT scanners (for example, i-CAT; Imaging Sciences International, Hatfield, PA, USA and NewTom 3G, QR, Verona, Italy) being capable of capturing the entire maxillofacial skeleton. Some CBCT scanners also allow the height of the cylindrical field of view to be adjusted to capture only the maxilla or mandibleCBCTTyagi SP, Sinha DJ, Verma R, Singh UP. New vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90113

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Based on tomosynthesis (Webber & Messura 1999).A series of 810 radiographic images are exposed atdifferent projection geometries using a programmable imaging unit, with specialized software to reconstruct a three-dimensional data set which may be viewed slice by sliceDiagnostic accuracy of TACT was superior to conventional two-dimensional radiography for the detection of vertical root fractures(Nair etal 2001,2003)Complex nature of the adjacent anatomy around posteriormaxillary molar teeth limits the use of TACT(Barton et l 2003)The resolution is reported to be comparable with 2D radiographs (Nair & Nair 2007).TACT is more diagnostically informative and had more impact on potential treatment options than conventional radiographs Cotti & Campisi 2004, Nair & Nair 2007, Patel et al.2007).

TACTTyagi SP, Sinha DJ, Verma R, Singh UP. New vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90115

Given radiographs taken in precisely the same positionand with the same beam geometry and exposure parameters,images can be subtracted to show changes overtime.Major drawbacks include difficulties experiencedin practice in achieving images with reproducible projectiongeometry over time.DIGITAL SUBTRACTION RADIOGRAPHYTyagi SP, Sinha DJ, Verma R, Singh UP. Newvistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90116

In a nutshell117

REFERENCES McDonald RE,Avery DR,Dean JE;Dentistry for the Child and Adolescent;2012;9Ed;ElsevierIngle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker IncVan Hassel HJ. Physiology of the human dental pulp. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1971;32(1):12634.Stephen R. Correlation of clinical tests with microscopic pathology of the dental pulp. J Dent Res 1937;6:26778. Mitchell DF, Tarplee RE. Painful pulpitis; a clinical and microscopic study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1960;13:136070.Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation correlations between diagnostic data and actual histologic findings in the pulp. Part I. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1963;16:84671.Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: correlations between diagnostic data and actual histologic findings in the pulp. Part II. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1963;16:96977.Johnson RH, Dachi SF, Haley JV. Pulpal hyperemiaa correlation of clinical and histologic data from 706 teeth. J Am Dent Assoc 1970;81(1):10817.Garfunkel A, Sela J, Ulmansky M. Dental pulp pathosis. Clinicopathologic correlations based on 109 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1973;35(1):11017.Bhaskar SN, Rappaport HM. Dental vitality tests and pulp status. J Am Dent Assoc 1973;86(2):40911.Hyman JJ, Cohen ME. The predictive value of endodontic diagnostic tests. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 1984;58(3):3436.Herbert W. A correlation between nervous accommodation, symptomatology and histological condition of the pulps of 52 teeth. Brit Dent J 1945;78:16173.Kulild JC, Weller RN. Endodontic diagnostic dilemmas. Med Bulletin 1988;PB-888:503.118

Keir DM, Walker WA III Schindler WG, Dazey SE. Thermally induced pulpalgia in endodontically treated teeth. J Endod 1991;17(1):3840.Ardekian L, Peleg M, Samet N, et al. Burkitts lymphoma mimicking an acute dentoalveolar abscess. J Endod1996;22(12):6978.Bellizzi R, Drobotij E, Keller D, Kenevan R. Sinusitis secondary to pregnancy rhinitis, mimicking pain of endodontic origin: a case report. J Endod 1983;9(2):604.Chelm-Berger D, Gutmann JL. Focal myositis mimicking posttreatment pain of periradicular origin. J Endod 1986;12(3):11923.Glickman GN. Central giant cell granuloma associated with a non-vital tooth: a case report. Int Endod J 1988;21(3):22430. 544 / EndodonticsJacobson JJ. Probe placement during electric pulp-testing procedures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1984;58(2):2427.Bender IB, Landau MA, Fonsecca S, Trowbridge HO. The optimum placement-site of the electrode in electric pulp testing of the 12 anterior teeth. J Am Dent Assoc 1989;118(3):30510119

Thank You120

Thank You(Basic)

To reproduce the video effects on this slide, do the following:

On the Home tab, in the Slides group, click Layout, and then click Blank.On the Insert tab, in the Media group, click Video, and then click Video from File. In the left pane of the Insert Video dialog box, click the drive or library that contains the video. In the right pane of the dialog box, click the video that you want and then click Insert.Under Video Tools, on the Format tab, in the Sizing group, click the arrow to the right of Size launching the Format Video dialog box, select Size from the left pane and under Size in the right pane do the following:Click the Lock Aspect Ratio box.In the Height box, enter 6.03.In the Width box enter 8.03. Also in the Format Video dialog box, click Border Color in the left pane, under Border Color in the right pane select Solid Line, and then click the arrow to the right of Color, and under Theme colors select Black, Text 1, Lighter 25% (fourth row, second option from left).Also in the Format Video dialog box, select Border Style in the left pane, under Border Style in the right pane set the Width to 15 pt.Also in the Format Video dialog box, select Shadow in the left pane, under Shadow in the Right pane, click the arrow to the right of Colors and under Theme Colors, select Black, Text 1 (first row, second option from left), and then do the following:In the Transparency box, enter 60%.In the Size box, enter 100%.In the Blur box, enter 21 pt.In the Angle box, enter 40 degrees.In the Distance box, enter 19 pt.Also in the Format Video dialog box, select 3-D Format in the left pane, under Bevel in the right pane click the arrow to the right of Top and under Bevel, select Relaxed Inset (first row, second option from left), and then do the following:To the right of Top, in the Width box, enter 6 pt.To the right of Top, in the Height box, enter 16.5 pt.On the Home tab, in the Drawing group, click Arrange, point to Align, and then do the following: Click Align Center.Click Align Middle. Under Video Tools, on the Playback tab, in the Video Options group, select Loop until Stopped.On the Animations tab, in the Animation group, select Play.On the Animations tab in the Timing group, click the arrow to the right of Start and select With Previous.

To reproduce the text effects on this slide, do the following:

On the Insert tab, in the Text group, click Text Box, and then on the slide drag to draw a text box.Type text in the text box (Thank You or whatever text suits your message).Select the text, on the Home tab, in the Font group, select Garamond from the Font list, select 88 pt from the Font Size list, and then click on the Bold icon.Also in the Home tab, in the Font group, select the arrow to the right of the Font Color Icon, and then under Theme Colors, select White, Background 1 (first row, first option from left).With the text box selected, under Drawing Tools, on the Format tab, click the arrow in the bottom right corner of the WordArt Styles group, click the arrow opening the Format Text Effects dialog box. In the Format Text Effects dialog box, click 3-D Format on the left pane, under Bevel on the right pane, click the arrow next to Top and under Bevel select Relaxed Inset (first row, second option from left). Set the Width to 5 pt and the Height to 3 pt.Also in the 3-D Format right pane, under Surface, click the arrow next to Material and under Special Effect select Dark Edge (first row, first option from left).Also in the 3-D Format right pane, under Surface, click the arrow next to Lighting and under Neutral select Soft (first row, third option from left).Also in the 3-D Format right pane, under Surface, set the Angle to 290 Degrees.Close the Format Text Effects dialog box.

To reproduce the background effects on this slide, do the following:

On the Design tab, in the bottom right corner of the Background group, click the arrow at the bottom right corner launching the Format Background dialog box.In the Format Background dialog box, select Fill in the left pane, and under Fill in the right pane select Solid fill, then click the arrow to the right of Color and under Theme Colors select White, Background 1, Darker 50% (sixth row, first option from left).Close the Format Background dialog.

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pulpal & periradicular diseases & their diagnosis

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