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Diagnosis of Pulpal and Periapical Diseases

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Diagnosis of Pulpal and Periapical Diseases Diagnosis of Pulpal and Periapical Diseases Sumamry This lesson will guide you through pulpal and periapical diagnosis, and simplify the sequelae of pulpitis. Overview It is extremely important to achieve the correct diagnosis before moving on to treatment The wrong diagnosis will lead to the wrong treatment If there are any uncertainties, it may be worth referring to a specialist to help establish the diagnosis or if the case is too complex and outside your capability Normal pulp Symptom-free Tooth will respond positively to sensitivity testing Normal periapical tissues Tooth is symptom free There is no tenderness to palpation or percussion Intact PDL ReviseDental.com Key words:¹ Acute Having a short course of severe symptoms Persisting for a long time Chronic It is possible to have acute episodes of chronic conditions Apical, periapical and Relating to the apex or tip of the root of the tooth periradicular Used interchangeably A well-developed capsule attached to the root apex Granuloma Contains chronic inflammatory cells surrounded by collagenous fibres Epithelial lined cavity filled with fluid Periapical cyst Bay cysts are attached to the root surface True cysts are not attached to the root surface Pulpal Diseases Reversible pulpitis Mild or transient pulpal inflammation Cause: Caries Exposed dentine Recent dental treatment Defective restoration Symptoms: Patients complain of a short sharp pain Initiated by cold and hot stimulus Radiographically: Periapical tissues appear normal The removal of caries or leaking restorations will usually relieve the symptoms IrreversibleReviseDental.com pulpitis The pulp is more severely affected and the inflammation is irreversible Causes: Caries Deep restorations Pulp exposure Any other direct or indirect insult to the pulp Symptomatic: Intermittent or spontaneous pain Initiated by hot or cold stimulus and prolonged episodes for minutes to hours Pain may be aching or dull, localised, diffuse or referred (irreversible pulpitis pain is nearly always aching or throbbing in nature, pain associated with dentine exposure is sharp) If untreated, will become necrotic Asymptomatic: Occasionally occurs when deep caries has not produced any symptoms 40% of irreversible pulpitis cases are asymptomatic If untreated, the tooth will become symptomatic or become necrotic Radiographically: Periapical tissues may appear normal Slightly widened PDL may be evident Root canal treatment or extraction is required Pulpal necrosis Can be partial or complete Causes: Following from symptomatic or asymptomatic irreversible pulpitis Caused by a loss of blood or inadequate blood supply Symptoms: The tooth may become sensitive to heat with partial pulpal necrosis Symptoms may result from the inflammatory reaction in the periapical tissues Radiographically The periapical tissues appear normal until they become infected and the periodontium is involved Root canal treatment or extraction is required Apical (Periapical) Diseases Acute Apical Periodontitis (symptomatic) Signs and symptoms: Exquisitely tender to touch, biting or percussion Radiographically There may be slight widening of the PDL Chronic ReviseDental.comApical Periodontitis (asymptomatic) There may not be any symptoms The patient may also report that the tooth 'feels different' or is slightly TTP Radiographically There may be a widening of the PDL A periapical radiolucency may be present 'Phoenix' abscess: acute exacerbation of chronic apical periodontitis Acute Apical Abscess Signs and symptoms Intense throbbing pain Very TTP and associated soft tissues tender to palpation Tooth may be mobile An intraoral or extraoral swelling may be visible In severe cases, there may be lymphadenopathy and malaise Radiographically There will be widening of the PDL There may or may not be a periapical radiolucency on a radiograph Chronic Apical Abscess There may not be any symptoms The patient may also report that the tooth 'feels different' on TTP but not sensitive Radiographically A periapical radiolucency is present Usually associated with a draining sinus tract An image to demonstrate a pulpal disease versus a periapical disease ReviseDental.com Spread of infection If the pulpal and periapical diseases are left untreated, the infection can spread into the soft tissues, blood or bone which can cause conditions which can be fatal. Osteomyelitis Painful bone infection Types: Suppurative osteomyelitis Non-suppurative osteomyelitis Signs and symptoms Tenderness, swelling around the affected bone Fever, fatigue Purulent Sinusitis Spread of infection from a maxillary tooth Signs and symptoms Nasal congestion Purulent rhinorrhea Postnasal drip Facial pain and pressure Referred pain to the ears and teeth Cellulitis Orbital cellulitis can occur from the spread of infection from a maxillary tooth Signs and symptoms: Protruding eye Pain, redness and swelling Inability to open the eye Vision loss, or impaired vision Ludwig's angina is a severe form of cellulitis. The origin can be a mandibular tooth infection Signs and symptoms: Pain in the floor of the mouth Difficulty swallowing Speech difficulties ReviseDental.comSwelling, redness and pain in the neck Cavernous sinus thrombosis The formation of a blood clot in the cavernous sinus due to the spread of infection from the head The blood clot prevents the infection from spreading further but causes restriction of blood flow to the brain Signs and symptoms: Sharp pain High temperature Feeling confused Vomiting Swelling, redness and pain in the eyes Vision problems Mediastinitis An infection affecting the mediastinum Signs and symptoms: Fever, rigor Shortness of breath and chest pain Swollen neck Confusion Parapharyngeal abscess Deep neck abscess Signs and symptoms: Fever Sore throat Painful swallowing Swelling in the neck ReviseDental.com Flow diagram to show the sequelae of pulpal disease ReviseDental.com Orofacial pain If after all of the testing procedures have been carried out and it has been decided that the pain is not of odontogenic origin, the patient should be referred to an orofacial pain clinic for further testing. Differential diagnosis of orofacial pain (coming soon in the oral medicine section) Neurologic e.g. trigeminal neuralgia An unusual local cause e.g. osteomyelitis Referred from a distant origin e.g. cardiac Psychogenic in origin e.g. atypical persistent facial pain Sinusitis Facial pain: Facial pain can have very similar symptoms to pulpal conditions and therefore can cause some confusion Symptoms: Throbbing, nagging, achy pain Doesn't tend to follow any anatomical boundaries May be a disturbance in sleep pattern Analgesics only 'take the edge off' the pain Other chronic pain conditions may be present e.g. headache, lower pack or abdominal pain Maxillary sinus ReviseDental.com Due to the close proximity of the sinus to the teeth in the maxillary arch, this can also cause confusion Symptoms: Acute sinusitis rarely occurs without preceding symptoms of a cold TTP of the whole quadrant of teeth is a usual sign Be aware that periradicular infection of premolar or molar teeth can lead to purulent discharge into the sinus with associated pain Conclusion The tooth demonstrates different symptoms depending on the extent of pulpal inflammation, necrosis and infection. If pulpal or periapical infections remain untreated, there is a chance they can develop into something more fatal. Patients may have symptoms which are closely related to the symptoms of a pulpal condition but instead are due to other conditions e.g. Facial pain and sinusitis Third Party Links References ¹Farlex, Medical Dictionary. The Free Dictionary Accessed May 1st, 2020. Hargreaves KM, Berman LH. Cohen's pathways of the pulp expert consult. Elsevier Health Sciences; 2015 Oct 2. link San Chong B. Harty's Endodontics in Clinical Practice E-Book. Elsevier Health Sciences; 2016 Jul 28. link Tronstad L. Clinical endodontics: a textbook. Stuttgart; New York: Thieme,; 2009. link National Health Service. Health A to Z. nhs.uk Health A to Z; Accessed May 2020 This content has been written by and uploaded to ReviseDental.com. It is the work of the author and should not be reproduced without express prior permission from the author through ReviseDental.com. © Revise Dental. 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