Transcript Toothaches of Dental Origin

Toothaches of Dental Origin
Diagnosis
and
Management
Material used by permission from B.C. Decker Publishing Co.
Initial Guidelines
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Before treating, determine a separate pulpal
and periapical diagnosis based on history
and responses to clinical tests.
Focus first on pulpal signs and symptoms, and
then periapical signs and symptoms.
Pulpal inflammation can eventually result in
periapical inflammation.
A tooth with a large periapical radiolucency must
have a necrotic pulp, if the lesion is of
endodontic origin.
Guidelines, con’t.
Post-op pain management for patients
requiring a pulpotomy or pulpectomy:
 Pre-emptive analgesia: prior to the
procedure, give the patient ibuprofen 600mg
plus acetaminophen 1000mg, orally.
 Contraindications: hypersensitivity to NSAIDs or
ASA, pregnancy, asthma, CHF, hypertension,
decreased renal or hepatic function, GI bleeding
or ulcers, or those on anticoagulant drugs.
 Injection of 0.5% marcaine following the
procedure.
PULPAL DISEASE
Classified as:
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Reversible pulpitis
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Irreversible pulpitis
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Necrotic pulp
Pulpal Disease
Reversible
Pulpitis
Reversible Pulpitis
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Condition should return to normal with
removal of the cause.
Common causes:
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Caries, recent restorative procedures, faulty
restorations, trauma, exposed dentinal
tubules, periodontal scaling.
Pulpal recovery will occur if reparative
cells in the pulp are adequate.
Symptoms of Reversible Pulpitis
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Thermal:
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Sweets:
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Hypersensitive with mild pain of <30 seconds, but
similar to control tooth
Sensitive (if caries, crack, or exposed dentin) with
mild pain of <30 seconds (similar to control tooth)
Biting Pressure:
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None (unless tooth is cracked)
Clinical Findings in
Reversible Pulpitis
Visual
Check for decay, fracture lines, swelling, sinus tracts,
orientation of tooth, and hyperocclusion
Palpation
Not sensitive
Percussion
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
Not necessary
Test cavity
Not necessary, tooth is vital
Radiographic
Periapical x-ray shows normal periapex
anesthesia
Diagnosis
Reversible Pulpitis
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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).
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If the tooth is percussion sensitive –
consider bruxism or hyperocclusion.
Treatment of Reversible Pulpitis
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Remove irritant if present (caries; fracture;
exposed dentinal tubules).
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If no pulp exposure: CaOH, restore, monitor
If pulp exposure:
Carious: initiate RCT
 Mechanical: >1 mm: initiate RCT
<1 mm crown planned: initiate RCT
<1 mm: direct cap or RCT
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If recent operative or trauma – postpone
additional treatment and monitor.
Pulpal Disease
Irreversible
Pulpitis
Irreversible Pulpitis
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Pulpal inflamation and degeneration not
expected to improve.
A physiologically older pulp has less ability to
recover due to decrease in vascularity and
reparative cells.
As inflammation spreads apically, cellular
organization begins to break down.
Localized pressure slows venous return,
resulting in buildup of toxins and lower pH that
causes widespread cellular destruction.
Symptoms of Irreversible Pulpitis
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Thermal:
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Sweets:
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Moderately to severely sensitive (if caries,
crack, or exposed dentin)
Biting Pressure:
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Hypersensitive with moderate to severe
prolonged pain (>30 seconds) as compared
to the control
Usually sensitive in later stages (periapical
symptom)
Moderate to severe spontaneous pain
Clinical Findings in
Irreversible Pulpitis
Visual
Check for decay, fracture lines, swelling, sinus tracts,
orientation of tooth, and hyperocclusion
Palpation
No response initially; may be sensitive in later stages
Percussion
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 suspected
Selective
May help identify offending tooth
Anesthesia
Test cavity
Not necessary, tooth is vital
Radiographic
Normal or thickened periodontal ligament
Diagnosis
Irreversible Pulpitis
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Hypersensitive to hot or cold that is
prolonged.
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A history of spontaneous pain.
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Vital or partially vital pulp.
Treatment of Irreversible Pulpitis
Minimum immediate treatment (if not extraction)
 Pulpotomy:
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Remove all decay (essential)
Large canals: passively broach 75% of tooth length
Small canals: spoon excavate orifice while removing
pulpal tissue from chamber.
Copious irrigation with sodium hypochlorite (1%).
Dry chamber with cotton pledget
Place Ca(OH)² into large and over small canals
Place dry cotton pellet in chamber, cover with cavit,
temporarily restore with Ketac-fill; completely relieve
occlusion if have acute apical peridontitis
Treatment of Irreversible Pulpitis
Ideal immediate treatment
 Pulpectomy (complete removal of pulpal tissue)
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Determine the ideal working length (WL)
Fully instrument canals with master apical file
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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 relieve
occlusion if have acute periapical peridontitis.
Ideal Access Preparations
Irreversible Pulpitis
(more treatment considerations)
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Any residual decay can result in an inadequate
seal, contamination of canal space, and interappointment flare-ups.
Inflammation can be judged by the amount of
hemorrhage from the remaining pulp stump. If
bleeding continues, re-broach or file for residual
pulpal tags with copious irrigation.
To decrease risk of instrument separation within
the canal space, do not engage the canal walls
with broach.
Irreversible Pulpitis
(additional considerations)
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Do not leave teeth open between appointments –
causes contamination of the canals and difficulty
closing them later.
Incomplete tooth fractures involving the pulp will
show symptoms of irreversible pulpitis.
Periodontal probing of associated pocket will
indicate depth of fracture. If depth of pocket
(fracture) extends below the attachment level,
the prognosis is guarded to poor.
Pulpal Disease
Necrotic
Pulp
Necrotic Pulp
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Results from continued degeneration of an
acutely inflamed pulp.
Involves a progressed breakdown of cellular
organization and no reparative potential.
Commonly have apical radiolucent lesion.
(always conduct proper pulp testing to rule out
a non-pulpal origin).
With multi-rooted teeth, one root may contain
partially vital pulp, whereas other roots may be
nonvital (necrotic).
Maxillary first molar with large amalgam restoration and
periapical radiolucencies around all three roots. The tooth
was unresponsive to electrical and thermal testing.
Periapical radiolucency of canine and premolar. The canine
was responsive to pulp and thermal testing.
Symptoms of Necrotic Pulp
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Thermal:
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Sweets:
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No response
Biting Pressure:
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No response
Usually moderate to severe pain (not symptom of
necrotic pulp, but rather periapical inflammation)
Moderate to severe spontaneous pain
(usually dull and throbbing; associated with periapical area)
Clinical Findings in
Necrotic Pulp
Visual
Check for decay, fracture lines, swelling, sinus tracts,
orientation of tooth, and hyperocclusion
Palpation
Sensitive
Percussion
Mild to severe pain (depends on periapex inflammation)
Mobility
None to moderate (depends on bone loss)
Perio Probing
WNL ( unless concomitant periodontal disease exists)
Thermal
No response
EPT
No response
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
Diagnosis of Necrotic Pulp
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Distinguishing features:
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No response to cold.
No response to EPT.
Caveats
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Decreased sensitivity to cold/ept may be from
of insulating effects of additional dentin.
Fluid in canal space conducting electrical
current can give false-positive.
Periapical radiolucency is strong but not
conclusive evidence that pulp is necrotic.
Treatment of Necrotic Pulp
Minimum immediate treatment (if not extraction)
 Partial instrumentation of canals:
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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)² into all canals
Place dry cotton pellet in chamber, cover with cavit,
temporarily restore with Ketac-fill; completely relieve
occlusion if have acute apical periodontitis.
Treatment of Necrotic Pulp
Ideal immediate treatment
 Complete instrumentation of canals:
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Determine the ideal working length
Fully instrument canals with master apical file
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


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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 relieve
occlusion if have acute apical periodontitis.
Necrotic Pulp
(additional considerations)
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Antibiotic coverage
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Pain Management
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Usually not required unless patient has progressive
swelling or fever.
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
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Reduction in all cases with acute apical periodontitis
(remember that length measurements may change)
PERIAPICAL DISEASE
Classified as:
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Acute Apical Periodonitis
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Acute Apical Abscess
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Chronic Apical Periodontitis
(Suppurative Apical Periodontitis with sinus tract)
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Condensing Osteitis
Treatment of Periapical Disease
Pulpal status
always dictates treatment
of periapical disease
Periapical Disease
Acute Apical
Periodontitis
Acute Apical Periodontitis
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Mild to severe inflammation that
surrounds or is closely associated with the
apex of a tooth.
Results from:
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Irreversible inflammation or necrotic pulp.
Trauma or bruxism of normal or reversibly
inflamed pulpitic conditions.
Consider vertical fractures, periodontal
abscess, and non-odontogenic pain.
Clinical Findings in
Acute Apical Periodontitis
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Visual
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Palpation
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Sensitive (usually on buccal surface)
Percussion
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Check for decay, fracture lines, swelling, sinus tracts, orientation
of tooth, and hyperocclusion
Moderate to severe (initially use index finger to reduce patient
discomfort)
Mobility
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Slight to no mobility (if moderate mobility exists, check for
possible periodontal condition before continuing)
Acute Apical Periodontitis, con’t.
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Perio Probing
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Thermal
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WNL (unless concomitant periodontal disease or vertical fracture
exists)
Response (not prolonged) – consider traumatic occlussion
If response prolonged – consider irreversible pulpitis
No response – consider necrotic pulp
EPT
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(pulpal symptom)
(pulpal test)
Response – pulp is vital (reversible or irreversible)
No response – pulp is necrotic
Acute Apical Periodontitis, con’t.
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Translumination
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Selective Anesthesia
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Not necessary, offending tooth easily located
Test cavity
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Not used unless fractured is suspected
Not necessary
Radiographic
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Periapical image does not show a radiolucent lesion; some
thickening of the periodontal ligament is common
Immediate Treatment of
Acute Periapical Periodontitis
If from irreversible pulpitis:
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Pulpotomy or extraction.
If from necrotic pulp:
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Root canal therapy initiated or extraction.
If from hyperocclusion:
When the pulp is normal or reversibly inflamed, adjusting the
occlusion provides immediate relief. Always consider cracked tooth,
irreversible pulpitis, or necrotic pulp if discomfort persists.
If from bruxism:
A biteguard may be indicated.
Periapical Disease
Acute Apical
Abscess
Acute Apical Abscess
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Acute inflammation of the periapical tissue
characterized by localized accumulation of
pus at the apex of a tooth.
A painful condition that results from an
advanced necrotic pulp.
Patients usually relate previous painful
episode from irreversible or necrotic pulp.
Swelling, tooth mobility, and fever are
seen in advanced cases.
Symptoms of Acute Apical Abscess
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Spontaneous dull, throbbing, persistent
pain; exacerbated by lying down.
Percussion:
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Mobility:
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Horizontal / vertical; often in hyperocclusion
Palpation:
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Extremely sensitive
Sensitive; vestibular or facial swelling likely
Thermal:
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No response
Clinical Findings of
Acute Apical Abscess
Visual:
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Check for decay, fracture lines, swelling, sinus tracts, orientation
of tooth, hyperocclusion
Palpation:
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sensitive; intraoral or extraoral swelling present
Percussion:
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Moderate to severe (initially use index finger)
Mobility:
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Slight to none; may be compressible
Perio probing:
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WNL (unless have perio disease or vertical fracture)
Acute Apical Abscess, con’t.
Thermal:
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No response (pulp is necrotic)
EPT:
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No response (false-positive from fluid in canal)
Translumination:
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Not used unless fractured is suspected
Selective Anesthesia:
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Not necessary, offending tooth easily located
Test cavity:
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Not necessary unless vitality is suspected
Acute Apical Abscess, con’t.
Radiographic:
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Thickening of the periodontal ligament is common; may not show a
frank lesion
If tests indicate pulp vitality: (red flag!)
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Review diagnostic information (repeat diagnostic tests)
Rule out lateral periodontal abscess
Review medical history for previous malignant lesions or
other conditions (hyperparathyroidism) that may explain
contradictory information
Do not begin treatment until this discrepancy has been
resolved
Treatment of Acute Apical Abscess
(necrotic pulp)
Minimum immediate treatment (if not extraction)
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Partial instrumentation of canals:
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



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
Treatment of Acute Apical Abscess,
con’t.
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Place Ca(OH)² 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 common
postoperative problems – so prepare the
patient for several days of discomfort.
Periapical Disease
Chronic Apical
Periodontitis
Chronic Apical Periodontitis
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Results from prolonged inflammation that has
eroded the cortical plate making a periapical
lesion visible on the radiograph.
Caused by a necrotic pulp, the lesion contains
granulation tissue consisting of fibroblasts and
collagen (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.
Chronic apical periodontitis. Extensive tissue destruction in
the periapical region of a mandibular first molar occurred
as a result of pulpal necrosis. Lack of symptoms together
with presence of a radiographic lesion is diagnostic.
Chronic Apical Periodontitis, con’t.
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Most common pitfall is assuming that the
presence of a periapical lesion automatically
indicates a necrotic pulp.
If tests indicate pulp vitality: (red flag!)
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Review diagnostic information (repeat diagnostic tests)
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Rule out lateral periodontal abscess, central giant cell
granuloma, traumatic bone cyst, and cemental dysplasia.
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Review medical history for previous malignant lesions or
other conditions (hyperparathyroidism) that may explain
contradictory information
Do not begin treatment until this discrepancy has been
resolved
Periapical radiolucencies associated with mandibular
incisors. These teeth were vital, and a diagnosis of
cemental dysplasia was made.
Treatment of Chronic Apical
Periodontitis (necrotic pulp)
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If asymptomatic, no immediate treatment
needed; schedule for root canal therapy
If in acute suppurative phase, immediate
treatment same as with acute apical abscess, i.e.,
Partial instrumentation of canals:
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
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Remove all decay, evaluate restorability
Determine working lengths 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 #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
Periodontitis, con’t.
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Copious irrigation with sodium hypochlorite (1%)
Dry chamber with cotton pledget
Place Ca(OH)² 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 common
postoperative problems – so prepare the
patient for several days of discomfort.
Periapical Disease
Condensing
Osteitis
Condensing Osteitis
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Increased trabecular bone in response to
persistent irritant diffusing from the root
canal into the periradicular tissue.
May be either asymptomatic (pulpal necrosis)
or associated with pain (pulpitis).
Therefore, may or may not respond to
diagnostic tests, i.e., thermal, electric,
palpation, percussion.
Root canal treatment, when indicated,
may result in complete resolution.
Inflammation followed by necrosis in the pulp of the first
molar has resulted in the diffuse radiopacity of the
periradicular tissue.