-
pulpal diagnosis
- alive: normal, reversible pulpitis, symptomatic or asymptomatic irreversible pulpitis
- dead: necrotic
-
apical diagnosis
- healthy: normal
- unhealthy: SAP, AAP, AAA, CAA
- Acute: new, symptomatic, early bone changes
- chronic: pre-existing, mild, bony change
-
Symptomatic irreversible pulpitis clues
- spontaneous
- woken up
- lingering
- heat sensitive
-
palpation dianoses what?
- inflammation through cortical plate
- pinkie over root apex
- not pulp test
-
percussion tests what?
- PDL inflammation (extension or infection)
- use metal mirror handle
- not pulp test
- lateral percussion for fractures
-
lateral percussion used for _____
fractures
-
mobility test:
- periradicular or perio disease
- root fracture
- bruxism
- use metal mirror handle w lateral force
- 0: barely discernable
- 1: less than 1mm
- 2: more than 1mm & vertical displacement
-
perio probing that are endo problems
- narrow, deep, vertical, isolated
- vs. broad, wide, generalized
probe until blanced w/ local anesthesia
-
cold test procedure
- isolate & dry
- incisal, middle, cervical
- avoid gingiva
- keep time
- +: normal, short, hypersensitvity
- -: could be necrotic
- materials: endo ice (fluoromethane), ice stick, dry ice (CO2), ice water w/ rubber dam, ethyl chloride
-
heat test procedure
- isolate & dry
- middle, cervical, not near gingiva
- material: heated GP & vaseline,
- + hot H2O&dam is usually abnormal
- not as useful
- use for hx of heat sensitivity or inconclusive cold
-
electric pulp procedure contraindicated for ____
pacemaker
-
electric pulp test
- isolate & dry
- middle/incisal thirds only
- not near gingiva
- tiny blob of toothpaste
- slow increase (4.5)
- +: <80 seconds
- -: repeat at 5.5
- false +: short cirucuit
-
tests for cracks & fractures
- transillumination
- methylene blue:
- microscope
- tooth slooth
-
symptoms of cracks & fractures
- cold sensitvity, tenderness on biting or pain on release.
- J shaped radiographic lesion
- narrow isolated vertical probing defect
- fat post, big restoration, bruxing
-
finding MB2
- wide MB root
- multiple xray angles
- double PDL outlines
- probe
- know anatomy
- dentinal map
- illumination
- magnification
-
reversible pulpitis symptoms & tx
- No spontaneous pain
- Responsive to cold, heat, EPT
- Short duration
- Moderate severity
- Monitor / reassure
- No intervention
- NSAID
- Seal exposed dentin (GLUMA or Hurriseal, etc)
- Caries removal & restoration
- Replace defective restoration
- Stop using acid drinks, sucking lemons, bleaching agents
-
symptomatic irreversible pulpitis symptoms
- Spontaneous pain, woken up
- Responsive to cold, heat, EPT
- Longer duration
- Increased severity
- +/- Periapical inflammation
-
asymptomatic irreversible pulpitis
- ● Vital inflamed pulp incapable of healing
- ● No clinical symptoms
- ● Inflammation from caries, caries excavation, trauma
- Pulp exposed by caries, pulp polyp
- Pulp exposure during operative procedure
- Pulp exposure due to trauma
-
pulp necrosis
- Death of the pulp
- ● Usually nonresponsive to testing (C-fibers, multicanal)
- No pulpal pain
- Nonresponsive to cold, heat, EPT
- Prior history / record of responsiveness
-
NORMAL APICAL TISSUES
- ● Not sensitive to percussion or palpation
- ● Lamina Dura is intact
- ● PDL space is uniform
- History normal
- Other findings from comprehensive eval normal
- No Intervention
-
SYMPT. APICAL PERIODONTITIS
- ● Inflammation, usually of apical periodontium
- ● Clinical symptoms
- ● Pain to biting, percussion, and/or palpation
- ● + Radiolucency
- Very, exquisitely, sensitive to percussion, biting
- Sometimes only slight PDL space thickening
- + Prior history of pulpitis
- Minor occlusal reduction
- RCT
- NSAID
-
ASYMPT. APICAL PERIODONTITIS
- ● Inflammation & destruction of apical periodontium
- ● No clinical symptoms
- ● Radiolucency present
- Slightly sensitive or “different” to percussion, biting
- Definite radiolucency present
- Minor occlusal reduction
- RCT
- NSAID
-
ACUTE APICAL ABSCESS
- ● Inflammatory reaction to pulpal infection / inflammation
- ● Rapid onset
- ● Spontaneous pain
- ● Tenderness of tooth to pressure
- ● Pus formation
- ● Swelling of associated tissues
- Signs of infection, redness, fever
- Minor occlusal reduction
- RCT
- NSAID
- Antibiotics if: fever, systemic, spreading, airway
- Drain & warm salt rinses if fluctuant swelling
- Trephinate apical bone if needed for drainage
-
CHRONIC APICAL ABSCESS
- ● Inflammatory reaction
- to pulpal infection / inflammation
- ● Gradual onset
- ● Little or no discomfort
- ● Tenderness of tooth to pressure
- ● Intermittent pus discharge through a sinus tract
- Definite radiolucency
- Trace sinus tract with GP X-ray
- + prior history of swelling / drainage
- Minor occlusal reduction
- RCT
- NSAID
-
CONDENSING OSTEITITIS
- ● Diffuse radiopaque lesion
- ● Localized bony inflammatory reaction to a low-grade stimulus
- ● Usually at tooth apex
- ● Tenderness of tooth to pressure
- Check pulpal diagnosis to confirm endodontic origin
- Condensing osteitis may co-exist with other apical diagnoses
- Minor occlusal reduction
- RCT
- NSAID
- SNW
-
LESION OF NON-ENDO ORIGIN
- ● Do not forget this possibility
- ● Exclude endo causes
- ● PCD, benign causes, malignant causes
- ● Normal anatomy eg mental foramen
- ● Refer appropriately
-
APICAL DIAGNOSIS SUMMARY
- • NORMAL
- • SYMPT APICAL PERIODONTITIS (SAP)
- Very sensitive to percussion
- Often slight thickening PDL space
- •ASYMPT APICAL PERIODONTITIS (AAP)
- PARL
- Can be asymptomatic
- Can have some percussion sensitivity
- • ACUTE APICAL ABSCESS (AAA)
- Clinical infection, swelling
- Fever: use antibiotics
- Fluctuant swelling: drain it
- • CHRONIC APICAL ABSCESS (CAA)
- Sinus tract & PARL
-
FEVER, SWELLING
- → AAA
- → I & D
- → Antibiotics
- → Admit if airway affected
- & don’t forget to do the RCT !
-
SINUS TRACT, PATENT PARULIS
- → CAA
- → X-ray with GP cone to trace
-
EXTREME COLD SENSITIVITY WITH PAIN ON BITING
- → Often a cracked vital tooth
- → Could be a rare SIP & SAP
-
LOCATION OF PARL
- Centered on cause of problem:
- e.g. Root canal portal of exit
- e.g. Lateral canal
- e.g. Missed canal
- e.g. Location of perforation
- e.g. Location of fracture
- Take off-angle films
- SNW
-
CRACKED TEETH
- Isolated vertical probing defect(s)
- “J” Shaped radiographic lesion
- Posts increase the risk
- Sensitivity on biting
- Pain on release
- “Tooth Slooth” positive on cusp(s)
- Visualization by transillumination
- Visualization by methylene blue stain
- Visualization by flapping to expose root
- Vizualization using miocroscope
-
NON-RESPONSIVE to COLD, HEAT, EPT:
- EITHER
- NECROTIC,
- OR
- ALIVE and the patient just didn’t feel it.
- CHECK: Was it previously responsive?
- CHECK: ALL OTHER FINDINGS.
-
Antibiotics are not effective in a root canal because
inadequate systemic circulation
-
Prophylactic Antibiotic Premedication (PAP) is recommended for patients of greatest risk of
- high-morbidity outcomes of
- Infective endocarditis
- including:
- Artificial heart valves
- History of IE
- Certain specific serious congenital heart conditions
-
Indication of Use of Antibiotics in Endodontic Treatment
- Systemic involvement
- Persistent infection
- Spreading infection
- 1. Fever, malaise, celluitis, unexpected trismus
- and progressive diffuse swelling, alone or in
- combination, are signs and symptoms of
- systemic involvement and spread of infection.
-
When antibiotics are prescribed in conjuction with debridement of the root canal system and soft tissue drainage, significant improvement should be seen within
48 hr
-
penicillin regimen
- effective against many of the bacteria found in
- polymicrobial endodontic infections, including
- anaerobes and Gram positive facultative
- bacteria(streptococci and enterococci).
- – About 10% of population may be allergic.
- – An initial oral loading dose of 1000mg of penicillin
- VK is followed by 500mg q6h for 7 days.
-
clindamycin
- Effective against many Gram positive and Gram
- negative microorganisms including both facultative
- and strict anaerobes.
- – It is well distributed throughout the body and reaches
- bone concentrations approaching that of plasma.
- – Clindamycin therapy has been associated with
- pseudomembranous colitis.
- – The usual adult dose if 150mg to 300mg q6hr for 7
- days.
-
Metronidazole
- – Bactericidal against anaerobes but does not have
- activity against aerobes or facultative anaerobes.
- – The addition of metronidazole to penicillin for a
- serious endodontic infection, especially in a medically
- compromised patient is appropriate.
- – The recommended dosage for a patient with an
- anaerobic infection is 250-500mg q6hr for 7 days
-
which antibiotic combination is useful in endodontic infections?
- Amoxicillin + Metronidazole
- To combat ulcer causing H. pylori.
-
Shaping
via files facilitates cleaning & obturation
-
irrigants
clean system and reach inaccessible areas
-
irrigant Properties
- – Tissue or Debris solvent
- – Toxicity
- – Low Surface Tension
- – Lubricant
- – Sterilization (Disinfectant)
- – Removal of Smear Layer
- – Other
- User Friendly
- Cost
- Shelf Life + Storage
- common: NaOCl 5.25% (sodium hypochlorite), EDTA 15%, Hydrogen Peroxide 3%, CHX Gluconate
-
Sodium Hypochlorite (NaOCl)
- 5.25% - dilute with equal parts water (2.6%) just
- as effective
- Potent antimicrobial agent
- Dissolved vital and nonvital tissues
- pH 11.0-11.5
-
RC Prep
- – Glycerin base lubricant
- – EDTA – chelator
- – Urea peroxide
- – Alternate with NaOCL – release Cl gas + O2 that will
- eliminate bacteria and sanitize canal.
-
Chlorhexidine Gluconate
- 2%
- Effective antimicrobial agent (Broad Spectrum)
- Low toxicity
- Not known to dissolve tissue
- Alternative with NaOCl for greater antimicrobial
- effect
-
Calcium Hydroxide
- Necrotic cases
- Mixed with water or glycerin
- Effective antimicrobial agent
- High pH, 12.5
- Takes 1 week in canal to be effective
- Does not infuse into dentinal tubules
- Pulp capping
- Interappointment canal dressing
- Apexification
-
Intracanal medicaments
- 2% Clindamycin – penetrates dentinal tubules
- 2% Chlorhexidine gel – E. Faecalis
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