toothaches of dental origin

7/31/2019 Toothaches of Dental Origin

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Toothaches of Dental Origin

Diagnosisand

Management

Material used by permission from B.C. Decker Publishing Co.


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Initial Guidelines

Before treating, determine a separate pulpaland periapical diagnosis based on historyand responses to clinical tests.

Focus first on pulpal signs and symptoms, andthen periapical signs and symptoms.

Pulpal inflammation can eventually result in

periapical inflammation.

A tooth with a large periapical radiolucency musthave a necrotic pulp, if the lesion is of

endodontic origin.


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Guidelines, cont.

Post-op pain management for patientsrequiring a pulpotomy or pulpectomy:

Pre-emptive analgesia: prior to theprocedure, give the patient ibuprofen 600mg

plus acetaminophen 1000mg, orally.

Contraindications: hypersensitivity to NSAIDs orASA, pregnancy, asthma, CHF, hypertension,

decreased renal or hepatic function, GI bleedingor ulcers, or those on anticoagulant drugs.

Injection of 0.5% marcaine following theprocedure.


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PULPAL DISEASE

Classified as:

Reversible pulpitis

Irreversible pulpitis

Necrotic pulp


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Pulpal Disease

Reversible

Pulpitis


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Reversible Pulpitis

Condition should return to normal withremoval of the cause.

Common causes:

Caries, recent restorative procedures, faultyrestorations, trauma, exposed dentinal

tubules, periodontal scaling.

Pulpal recovery will occur if reparativecells in the pulp are adequate.


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Symptoms of Reversible Pulpitis

Thermal:

Hypersensitive with mild pain of


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Clinical Findings inReversible Pulpitis

Visual Check for decay, fracture lines, swelling, sinus tracts,orientation of tooth, and hyperocclusion

Palpation Not sensitive

Percussion Not sensitive

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

anesthesiaNot necessary

Test cavity Not necessary, tooth is vital

Radiographic Periapical x-ray shows normal periapex


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DiagnosisReversible Pulpitis

If there is a discrepancy between thepatients chief complaint, symptoms, andclinical 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 onlycondition, the periapical area should be normal).

If the tooth is percussion sensitiveconsider bruxism or hyperocclusion.


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Treatment of Reversible Pulpitis

Remove irritant if present (caries; fracture;exposed dentinal tubules).

If no pulp exposure: CaOH, restore, monitor

If pulp exposure: Carious: initiate RCT

Mechanical: >1 mm: initiate RCT


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Pulpal Disease

Irreversible

Pulpitis


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Irreversible Pulpitis

Pulpal inflamation and degeneration notexpected to improve.

A physiologically older pulp has less ability to

recover due to decrease in vascularity andreparative cells.

As inflammation spreads apically, cellularorganization begins to break down.

Localized pressure slows venous return,resulting in buildup of toxins and lower pH thatcauses widespread cellular destruction.


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Symptoms of Irreversible Pulpitis

Thermal: Hypersensitive with moderate to severe

prolongedpain (>30 seconds) as comparedto 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 spontaneouspain


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Clinical Findings inIrreversible Pulpitis


Palpation No response initially; may be sensitive in later stages

Percussion No response initially; may be sensitive in later stages

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 suspectedSelective

Anesthesia

May help identify offending tooth

Test cavity Not necessary, tooth is vital

Radiographic Normal or thickened periodontal ligament


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Treatment of Irreversible Pulpitis

Minimum immediate treatment (if not extraction)

Pulpotomy:

Remove all decay (essential)

Large canals: passively broach 75% of tooth length

Small canals: spoon excavate orifice while removingpulpal tissue from chamber.

Copious irrigation with sodium hypochlorite (1%).

Dry chamber with cotton pledget

Place Ca(OH) into large and oversmall canals

Place dry cotton pellet in chamber, cover with cavit,temporarily restore with Ketac-fill; completely relieveocclusion if have acute apical peridontitis


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Treatment of Irreversible Pulpitis

Ideal immediate treatment Pulpectomy(complete removal of pulpal tissue)

Determine the ideal working length (WL)

Fully instrument canals with master apical file At least # 25 file for small canals (and anterior teeth)

# 35 - 40 file for larger canals

Alternate working files with #8 or 10 patency file

Copious irrigation with sodium hypochlorite (1%)

Dry chamber with cotton pledget

Place dry cotton pellet over canals, cover with cavit,temporarily restore with Ketac-fill; completely relieveocclusion if have acute periapical peridontitis.


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Ideal Access Preparations


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Irreversible Pulpitis(more treatment considerations)

Any residual decay can result in an inadequateseal, contamination of canal space, and inter-appointment flare-ups.

Inflammation can be judged by the amount ofhemorrhage from the remaining pulp stump. Ifbleeding continues, re-broach or file for residual

pulpal tags with copious irrigation. To decrease risk of instrument separation within

the canal space, do notengage the canal wallswith broach.


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Irreversible Pulpitis(additional considerations)

Do not leave teeth open between appointmentscauses contamination of the canals and difficultyclosing them later.

Incomplete tooth fractures involving the pulp willshow symptoms of irreversible pulpitis.

Periodontal probing of associated pocket willindicate depth of fracture. If depth of pocket(fracture) extends below the attachment level,the prognosis is guarded to poor.


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Pulpal Disease

Necrotic

Pulp


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Necrotic Pulp

Results from continued degeneration of anacutely inflamed pulp.

Involves a progressed breakdown of cellular

organization and no reparative potential. Commonly have apical radiolucent lesion.

(alwaysconduct proper pulp testing to rule outa non-pulpal origin).

With multi-rooted teeth, one root may containpartially vital pulp, whereas other roots may benonvital (necrotic).


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Maxillary first molar with large amalgam restoration andperiapical radiolucencies around all three roots. The toothwas unresponsive to electrical and thermal testing.


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


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Symptoms of Necrotic Pulp

Thermal: No response

Sweets: No response

Biting Pressure:

Usually moderate to severe pain (not symptom ofnecrotic pulp, but rather periapical inflammation)

Moderate to severe spontaneouspain(usually dull and throbbing; associated with periapical area)

Cli i l Fi di i


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Clinical Findings inNecrotic Pulp


Palpation Sensitive

Percussion Mild to severe pain (depends on periapex inflammation)

MobilityNone to moderate (depends on bone loss)

Perio Probing WNL ( unless concomitant periodontal disease exists)

Thermal No response

EPT No response

Translumination Not used unless fracture is suspectedSelectiveanesthesia

May help identify offending tooth

Test cavity May be used if vitality is suspected

Radiographic Periapical radiograph may show normal or thickenedperiodontal ligament, or radiolucent lesions


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Diagnosis of Necrotic Pulp

Distinguishing features: No response to cold.

No response to EPT.

Caveats

Decreased sensitivity to cold/ept may be fromof insulating effects of additional dentin.

Fluid in canal space conducting electricalcurrent can give false-positive.

Periapical radiolucency is strong but not

conclusive evidence that pulp is necrotic.


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Treatment of Necrotic Pulp

Minimumimmediate treatment (if not extraction)

Partial instrumentation of canals: Remove all decay, evaluate restorability

Determine working length of all canals

Large canals: up to #40 file, 4mm short of WL Small canals: up to #25 file, 4mm short of WL

Alternate working file with #8 or 10 patency file

Copious irrigation with sodium hypochlorite (1%)

Dry chamber with cotton pledget Place Ca(OH) into all canals

Place dry cotton pellet in chamber, cover with cavit,temporarily restore with Ketac-fill; completely relieveocclusion if have acute apical periodontitis.


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Treatment of Necrotic Pulp

Ideal immediate treatment

Complete instrumentation of canals:

Determine the ideal working length

Fully instrument canals with master apical file At least # 25 file for small canals (and anterior teeth)

# 35 - 40 file for larger canals

Alternate with #8 or 10 patency file

Copious irrigation with sodium hypochlorite (1%) Place dry cotton pellet over canals, cover with cavit,

temporarily restore with Ketac-fill; completely relieveocclusion if have acute apical periodontitis.


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Necrotic Pulp(additional considerations)

Antibiotic coverage Usually not required unless patient has progressive

swelling or fever.

Pain Management Always determine allergy, contraindication, and

interaction with present medications

Clock regulate NSAID (ibuprofen) for 3 days

Narcotic for approximately 3 days, if needed

Occlusal Reduction Reduction in all cases with acute apical periodontitis

(remember that length measurements may change)


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PERIAPICAL DISEASE

Classified as:

Acute Apical Periodonitis

Acute Apical Abscess

Chronic Apical Periodontitis

(Suppurative Apical Periodontitis with sinus tract)

Condensing Osteitis


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Treatment of Periapical Disease

Pulpal status

always dictates treatment

of periapical disease


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Periapical Disease

Acute Apical

Periodontitis


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Acute Apical Periodontitis

Mild to severe inflammation thatsurrounds or is closely associated with the

apex of a tooth. Results from:

Irreversible inflammation or necrotic pulp.

Trauma or bruxism of normal or reversiblyinflamed pulpitic conditions.

Consider vertical fractures, periodontalabscess, and non-odontogenic pain.

l l d


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Clinical Findings inAcute Apical Periodontitis

Visual Check for decay, fracture lines, swelling, sinus tracts, orientation

of tooth, and hyperocclusion

Palpation Sensitive (usually on buccal surface)

Percussion Moderate to severe (initially use index finger to reduce patient

discomfort)

Mobility Slight to no mobility (if moderate mobility exists, check for

possible periodontal condition before continuing)


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Acute Apical Periodontitis, cont.

Perio Probing

WNL(unless concomitant periodontal disease or vertical fracture

exists)

Thermal (pulpal symptom) Response (not prolonged) consider traumatic occlussion

If response prolonged consider irreversible pulpitis

No response consider necrotic pulp

EPT (pulpal test) Response pulp is vital (reversible or irreversible)

No response pulp is necrotic


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Acute Apical Periodontitis, cont.

Translumination Not used unless fractured is suspected

Selective Anesthesia Not necessary, offending tooth easily located

Test cavity Not necessary

Radiographic Periapical image does not showa radiolucent lesion; some

thickening of the periodontal ligament is common


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Immediate Treatment of

Acute Periapical PeriodontitisIf from irreversible pulpitis: Pulpotomy or extraction.

If from necrotic pulp: Root canal therapy initiated or extraction.

If from hyperocclusion:When the pulp is normal or reversibly inflamed, adjusting theocclusion provides immediate relief. Always consider cracked tooth,irreversible pulpitis, or necrotic pulp if discomfort persists.

If from bruxism:

A biteguard may be indicated.


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Periapical Disease

Acute Apical

Abscess


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Acute Apical Abscess

Acute inflammation of the periapical tissuecharacterized by localized accumulation ofpus at the apex of a tooth.

A painful condition that results from anadvanced necrotic pulp.

Patients usually relate previous painful

episode from irreversible or necrotic pulp.

Swelling, tooth mobility, and fever areseen in advanced cases.


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Symptoms ofAcute Apical Abscess

Spontaneous dull, throbbing, persistentpain; exacerbated by lying down.

Percussion:

Extremely sensitive Mobility:

Horizontal / vertical; often in hyperocclusion

Palpation: Sensitive; vestibular or facial swelling likely

Thermal: No response

Cli i l Fi di f


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Clinical Findings ofAcute Apical Abscess

Visual: Check for decay, fracture lines, swelling, sinus tracts, orientation

of tooth, hyperocclusion

Palpation: sensitive; intraoral or extraoral swelling present

Percussion: Moderate to severe (initially use index finger)

Mobility: Slight to none; may be compressible

Perio probing:

WNL (unless have perio disease or vertical fracture)


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Acute Apical Abscess, cont.

Thermal: No response (pulp is necrotic)

EPT: No response (false-positive from fluid in canal)

Translumination: Not used unless fractured is suspected

Selective Anesthesia: Not necessary, offending tooth easily located

Test cavity: Not necessary unless vitality is suspected


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Acute Apical Abscess, cont.

Radiographic: Thickening of the periodontal ligament is common; may not show a

frank lesion

If tests indicate pulp vitality: (red flag!) Review diagnostic information (repeat diagnostic tests)

Rule out lateral periodontal abscess

Review medical history for previous malignant lesions orother conditions (hyperparathyroidism) that may explaincontradictory information

Do not begin treatment until this discrepancy has beenresolved


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Treatment ofAcute Apical Abscess(necrotic pulp)

Minimumimmediate treatment (if not extraction)

Partial instrumentation of canals: Remove all decay, evaluate restorability Determine working length of all canals Achieve apical patency all canals with #10 file, look for

drainage and allow to continue until it stops Large canals: up to #40 file, 4mm short of WL Smaller canals: up to #25 file, 4mm short of WL

Alternate with #8 or 10 patency file Copious irrigation with sodium hypochlorite (1%) Dry chamber with cotton pledget

continued on next slide


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Treatment ofAcute Apical Abscess,cont.

Place Ca(OH) into all canals

Place dry cotton pellet in chamber, cover with cavit,temporarily restore with Ketac-fill, and completely

relieve tooth from occlusion. Incision and drainage may be required

Prescribe antibiotics and analgesics

Continued pain and swelling are commonpostoperative problems so prepare thepatient for several days of discomfort.


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Periapical Disease

Chronic Apical

Periodontitis


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Chronic Apical Periodontitis

Results from prolonged inflammation that haseroded the cortical plate making a periapicallesion visible on the radiograph.

Caused by a necrotic pulp, the lesion containsgranulation tissue consisting of fibroblasts andcollagen (with macrophages and lymphocytes).

Must rule out central giant cell granuloma,

traumatic bone cyst, and cemental dysplasia. Usually asymptomatic, but in acute phase may

cause a dull, throbbing pain.


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Chronic apical periodontitis. Extensive tissue destruction inthe periapical region of a mandibular first molar occurredas a result of pulpal necrosis. Lack of symptoms together

with presence of a radiographic lesion is diagnostic.


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Chronic Apical Periodontitis, cont.

Most common pitfall is assuming that thepresence of a periapical lesion automaticallyindicates a necrotic pulp.

If tests indicate pulp vitality: (red flag!)

Review diagnostic information (repeat diagnostic tests)

Rule out lateral periodontal abscess, central giant cellgranuloma, traumatic bone cyst, and cemental dysplasia.

Review medical history for previous malignant lesions orother conditions (hyperparathyroidism) that may explaincontradictory information

Do not begin treatment until this discrepancy has beenresolved


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Periapical radiolucencies associated with mandibularincisors. These teeth were vital, and a diagnosis ofcemental dysplasia was made.

Treatment of Chronic Apical


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Treatment ofChronic ApicalPeriodontitis(necrotic pulp)

If asymptomatic, no immediate treatmentneeded; schedule for root canal therapy

If in acute suppurative phase, immediatetreatment same as with acute apical abscess, i.e.,

Partial instrumentation of canals: Remove all decay, evaluate restorability

Determine working lengths of all canals

Achieve apical patency all canals with #10 file, look fordrainage and allow to continue until it stops

Large canals: up to #35 file, 4mm short of WL

Smaller canals: up to #25 file, 4mm short of WL

Alternate with #8 or 10 patency file

Treatment of Chronic Apical


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Treatment ofChronic ApicalPeriodontitis, cont.

Copious irrigation with sodium hypochlorite (1%) Dry chamber with cotton pledget

Place Ca(OH) into all canals

Place dry cotton pellet in chamber, cover with cavit,

temporarily restore with Ketac-fill, and completelyrelieve tooth from occlusion.

Incision and drainage may be required

Prescribe antibiotics and analgesics

Continued pain and swelling are commonpostoperative problems so prepare thepatient for several days of discomfort.


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Periapical Disease

Condensing

Osteitis


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Condensing Osteitis

Increased trabecular bone in response topersistent irritant diffusing from the rootcanal into the periradicular tissue.

May be either asymptomatic (pulpal necrosis)or associated with pain (pulpitis).

Therefore, may or may not respond todiagnostic tests, i.e., thermal, electric,palpation, percussion.

Root canal treatment, when indicated,may result in complete resolution.


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Inflammation followed by necrosis in the pulp of the firstmolar has resulted in the diffuse radiopacity of theperiradicular tissue.

toothaches of dental origin

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