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232 Cards in this Set
- Front
- Back
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Diagnosis' First Step
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Gather Info
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In patietnt's own words
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Chief Complaint
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Gathering info
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CC
Medical/Dental Hx Symptoms-subjective info Signs-objective info |
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Vital Signs
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BP
Pulse Temperature |
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Temperature is important in patients with____
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infection
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-General appearance and symmetry
-Swelling of fascial spaces -Redness, Discoloration -Lymphadenopathy - TMJ |
Extraoral Exam
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- Soft tissues
- Generalized state of dentition |
Soft Tissue Exam
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small fluctuant swelling with draining area
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parulis
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draining area
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stoma
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associated with sinus tract
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stoma
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used to trace sinus tract
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large gutta percha
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- Caries
- Restorations - Fractures - Discoloration - Abrasions and Erosions |
dental exam
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primary endo radiograph is the ______
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PA
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helps evalulate restorability
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BWs
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Can a panorex diagnose endo disease?
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HELL NO
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IMPORTANT in Diagnostic Tests
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Reproduce patients complaint
Test adjacent teeth as they could be causing the pain Test contra-lateral teeth as baseline too |
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periodontal tests
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probing depths
mobility |
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Periapical tests
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percussion
palpation bite |
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Sensibility (vitality testing)
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cold
ept to confirm heat (indicated by symptoms)-not a primary test |
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determines how far the inflammation has extended
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palpation
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palpation: painful response indicates periapical ______
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inflammation
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percussion: tooth tapped in _______ direction
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apical
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percussion: tooth is sore then it indicates periapical ______
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inflammation
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most reliable to see which tooth causes the pain
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percussion
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Percussion/Palpation Readings
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N = No pain
+ = Slight pain ++ = Moderate pain +++ = Severe pain |
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PA tests: Biting Force with tooth sleuth
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Suspected fracture of tooth or cusp.
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Cracked tooth/fractured cusp hurts
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Rebound sensitivity, bite on the sleuth, and when you release, opens the tooth and causes problems
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cold test is applied on _____ surface of tooth
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buccal
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cold test can be applied on
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teeth and full coverage restorations
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cold test is more effective on anterior or posterior teeth
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anterior
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cold test: abnormal response
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prolonged and severe
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cold test: necrotic pulp
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no response
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Cold test: false positive
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apply cold and it drips to adjacent tooth
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cold test: false negative
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receded or restricted pulps
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material used for cold testing
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large #2 cotton pellet
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why is #2 cotton pellet the best?
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lowest intrapupal temp change and best response to cold
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whats better to use, CO2 snow or endo ice?
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endo ice
CO2 snow is difficult to make and endo ice is easier to use and quicker response too |
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Cold readings
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0 = No pain
+ = Slight pain immediately reversed ++ = Moderate pain immediately reversed +++ = Severe pain that does not go away when stimulus is removed |
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delivers a direct current of high frequency electricity to intact tooth structure
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EPT
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secondary to cold test
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EPT
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EPT Method
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-Teeth isolation and drying with air syringe
Toothpaste on electrode as conductor The electric circuit is completed by patient touching the metal handle Electrode is placed on buccal or occlusal surface 80/80 reading= no response to electrical stimulation |
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EPT can be done on
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teeth, BUT NOT on full coverage crowns/restorations
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hot water
dry rubber prophy heated gutta percha |
heat test
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must need rubber dam isolation
not a routine test wait 2min for each tooth |
heat test
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indications for heat test
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when heat is a symptom and cant be reproduced
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identify longitudinal fracture of crown
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transillumination
fractured tooth does not transmit light |
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endodontic diagnosis
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MUST make BOTH a pulpal and periapical diagnosis
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A clinical diagnostic category in which the pulp is symptom free and normally responsive to vitality testing.
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Normal Pulp
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Diagnostic: Normal Pulp
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Cold response:
Low grade or immediate reverse: + May have no response from receded or sclerotic pulp:0 |
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A clinical diagnosis based upon subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal.
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Reversible Pulpitis
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Inflammation should resolve and go back to normal. Remove irritation from pulp.
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Reversible Pulpitis
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Diagnostic: Reversible Pulpitis
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Cold: elevated but reversed: ++
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A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing.
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Irreversible pulpitis
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Lingering thermal pain, spontaneous pain, referred pain
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Symptomatic
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No clinical symptoms but inflammation produced by caries, caries excavation, trauma, etc.
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Asymptomatic
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high as 40-60% inflammed and have no symptoms. Seen in caries extended to pulp and are asymptomatic. Seen in clinic. Normal test, but not normal because it is irreversible and they just didn’t have any symptoms.
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asymptomatic irreversible pulpitis
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Diagnostic: symptomatic Irreversible Pulpitis
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cold test elevated and prolonged that does not go away when removed:+++
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Diagnostic: asymptomatic Irreversible Pulpitis
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cold: same as normal pulp
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A clinical diagnostic category indicating death of the dental pulp. The pulp is non-responsive to vitality testing.
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pulp necrosis
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Diagnostic: Pulp Necrosis
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No response to cold
No response to EPT 80/80 |
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A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials, other than intracanal medicaments.
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Previously Treated
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Tooth already had a RCT, diagnosis with radiograph. And filled with permanent material. Done radiographically not clinically.
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Previously Treated
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Diagnostic: Previously Treated
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Respond to Cold and EPT as necrotic
Can respond as vital with remaining vital tissue(2 of 3 roots done, remaining root still has vital tissue) |
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A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (e.g. pulpotomy, pulpectomy)
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Previously Initiated Therapy
seen on radiograph only |
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Diagnostic: Previously Initiated Therapy
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same as previously treated
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Teeth with normal periradicular tissues that will not be abnormally sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact and the periodontal ligament space is uniform.
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normal apical tissues
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diagnostic: normal apical tissues
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No sensitivity to percussion (recorded as N)
No sensitivity to palpation (recorded as N) |
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Inflammation, usually of the apical periodontium, producing clinical symptoms including painful response to biting and percussion. It may or may not be associated with an apical radiolucent area
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symptomatic apical periodontitis
*IF YOU DONT SEE APICAL RL, YOU CANNOT RULE OUT APICAL PERIO* |
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diagnostic: symptomatic apical periodontitis
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Positive to percussion
May or may not be positive to palpation |
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Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area and does not produce clinical symptoms.
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Asymptomatic apical periodontitis
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Associated with necrotic teeth and seen on radiograph. And seen with RL around the tooth. Usually a radiographic evidence.
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Asymptomatic apical periodontitis
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Diagnostic: Asymptomatic Apical Periodontitis
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Negative to percussion
Negative to palpation |
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An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation and swelling of associated tissues.
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Acute apical abscess
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Worst/most severe. Inflmmatory reaction. Rapid onset. Rapidly progressing inection
Swelling and rapid on set and a lot of pain |
acute apical abscess
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diagnostic: acute apical abscess
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Percussion positive
Palpation positive |
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An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort, and intermittent discharge of pus through an associated sinus tract.
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Chronic Apical Abscess
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Diagnostic: Chronic Apical Abscess-
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Percussion negative
May be palpation positive if sinus tract is palpated |
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Pulp Diagnosis'
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Normal Pulp
Reversible Pulpitis Irreversible pulpitis Pulp necrosis Previously Treated Previously Initiated Therapy |
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Periapical Diagnosis'
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Normal apical tissues
Symptomatic apical periodontitis Asymptomatic apical periodontitis Acute apical abscess Chronic Apical Abscess |
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intact tissue
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vital
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poly microbial bacteria and necrotic tissue
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necrotic
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complex network of biologic tissue
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root canal system
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biological aim of cleaning and shaping
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1.removal of pulp tissue or pulp tissue remnants
2. removal of infected dentin 3. disinfection to remove bacteria |
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to understand pulp anatomy
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use radiographs to get 3d representation
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cleaning and shaping debridement consist of 2 components
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chemical and mechanical
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used in order to clean and disinfect
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irrigants
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used to shape the canal and remove infected dentin
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files
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defines the apical extent in which to remove tissue
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the apex
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most apical extent of the root as visualized on the radiograph
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major constriction
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0.5-1mm short of the apex. apical stop. Shape until this point
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minor constriction
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cementodentinal junction
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minor constriction
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narrowest site of the apical foramen
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minor constriction
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instruments used to shape the canal and remove tissue
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hand files-k files
rotary instruments |
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used to estimate length from incisal to apex of a tooth
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radiography
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measured impedance at the level of the pdl in locating the apex. helps in identifying the lvel of the minor constriction
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Electronic Apex Locator-EAL
When the file reaches the minor constriction a visual picture and a sound is heard Tells operator length of canal space to be cleaned & shaped |
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Objectives of Mechanical Shaping
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1.Leave as much radicular dentin as possible yet enlarge adequately to remove tissue & infected dentin
2.Maintain original shape of the canals yet enlarge that shape uniformly from apex to coronal 3.Shape canal to a size that can be easily obturated |
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Goal of Mechanical Shaping
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Continued Tapered Funnel Shaped Preparation
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Allows to clean and shape from crown to apex. Use various instruments to shape and clean the following 3 spaces: Coronal 3rd, Middle 3rd, and Apical 3rd
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Crown Down Technique
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Instruments for finding the pathway from the orifice to the apex
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Hand Files
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Instruments for shaping the Coronal Third
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Oriface Shapers
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Instruments for shaping the remainder of the canal to the minor diameter
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Rotary Instruments
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Size #6, 8, 10, 15, 20
Stainless steel Held in hand |
K Files
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Used to establish a working length and investigate apical foramen
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Hand Files
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Instruments to define the orifice and shape
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Gate-Gliddens
Oriface Shapers |
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#2 and 3 used most often
Operated in slow-speed or electric handpiece |
Gate-Gliddens
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Operated in electric handpiece-nickel titanium
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Orifice Shapers
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bends without permanent deformation so great for curved canals
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Nickel Titanium Rotary Instruments
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Use irrigants that “clean” and “disinfect”
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Chemical Debridement Component
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Irrigants Used
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NaOCl
EDTA Chlorhexidine |
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remove vital and necrotic tissue
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NaOCl
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remove smear layer on walls of the canal after preparation with instruments
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EDTA
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disinfect canal space
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Chlorhexidine
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Goals of Preparation
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1.Confine root canal preparation to the canal space
2.Prepare canal to 0.5 to 1.0 mm short of the apical constriction 3.Produce a continually tapered funnel shaped preparation 4.Disinfect the canal |
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Steps in root canal preparation using the Crown Down Technique
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1.Shape the canal as you prepare the canal
2.Clean the canal from orifice to apex 3.Apical preparation (apical diameter at the narrowest point) |
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Objectives of Shaping
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Provide better access for the cleaning and irrigating the canal space.
Create a tapered preparation to facilitate obturation (sealing of the canal system). |
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Failure in shaping
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1.Inadequate cleaning of the root canal space
2.Inadequate obturation (sealing of the root canal space. 3.Treatment failure |
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Reasons to not instrument a canal while its dry
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1. Create dust and chunks of dentin that would clog the canal space.
2. Create frictional heat. |
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Positives for working in a wet environment
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1.Flushes and Floats debris from the canal space
2.Cools instruments working in the canal space |
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Ideal Properties of an Irrigating Solution
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dissolve vital and necrotic pulp tissue
antimicrobial lubricates low surface tension removes biofilm removes smear layer readily available inexpensive adequate shelf life non-staining |
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Safest Irrigating Agents
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Water or Saline
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Properties of Water and Saline
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Cheap
Non-Toxic Non staining Is not antimicrobial, does not dissolve tissue, has no effect on smear layer |
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Most Popular Irrigant
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Sodium HypoChlorite-NaOCl
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Advantages of NaOCl
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antimicrobial
dissolves vital and necrotic pulp tissue inexpensive and readily available removes organic portion of smear layer |
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Disadvantages of NaOCl
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toxic to vital tissue
dangerous if extruded from canal space |
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Concentration of NaOCl used in clinic
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2.6%
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Effective irrigant against E. Faecalis
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2% Cholhexidine
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Advantages of Chlorhexidine
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Effective antimicrobial
Sometimes mixed with surfactant to reduce surface tension Low to moderate toxicity |
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Disadvantage of Chlorhexidine
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Does not dissolve tissue
Expensive |
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Organic pulpal material and inorganic dentinal debris accumulating in the dentinal tubules
1-5 microns thick Can be contaminated with bacteria 10-150 microns into the tubules |
Smear Layer
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Effective in removing organic portion of Smear Layer
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NaOCl
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Effective in removing non-organic portion of smear layer
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17% EDTA
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Clinic Protocol: Irrigation
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Half Strength NaOCl as Primary Irrigant
17% EDTA as final irrigant for 1 minute prior to obturation Flush with saline Final irrigation with 2% Chlorhexidine for 1 minute |
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Remain active when it binds to the dentin for 72 hrs. extended antimicorbial activity. They are gonna go into the tubules. valuable in killing residual bacterial.
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CHX
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NaOCl with 2% Chlorhexidine forms
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brown precipitate (parachloroaniline) which is potentially carcinogenic
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EDTA with 2% Chlorhexidine forms
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white precipitate (salt) which is harmless-still clogs the canals
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Unproven controversial ways of enhancing irrigation
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Heating NaOCl
Sonic Activation |
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suction at root apex, and solution at coronal, pulls liq down
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Negative Pressure
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Fill tooth with solution and put tip in and activate it . Creates waves. Called acoustic streaming. Force of ultrasound and drives fluid to remove tissue and bacteria
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Ultrasonic Irrigation
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Used only with hand files
DO NOT use with rotary instruments Acts as chelating agent-softens hard dentin |
Lubricant
Clinic: RC Prep |
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_____% of the U.S. population experiences a toothache within a 6 month timeframe
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12
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Vital Pulp Diagnoses with no Emergency Treatment Required
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1.Normal pulp
2.Reversible pulpitis 3.Asymptomatic Irreversible Pulpitis |
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Vital Pulp Diagnoses with Emergency Treatment Required
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Symptomatic Irreversible Pulpitis
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Characteristics of Irreversible Pulpitis
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1.Thermal sensitivity
2.Symptomatic apical periodontitis may or may not be present 3.No swelling 4.Anesthesia problems common, particularly in mandibular teeth |
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removal of coronal pulp
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Pulpotomy
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removal of pulp from all canals without canal shaping (usually without a working length radiograph)
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Gross Pupal debridement
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removal of coronal pulp and pulp from main canal
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Partial pulpectomy
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complete cleaning and partial or complete shaping
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Total pulpectomy
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entire obturation and instrumentation
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complete endodontic therapy
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Treatment Options for Single Rooted Teeth
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Gross pulpal debridement
Total Pulpectomy Complete Endodontic Therapy |
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Treatment Options: Multi-Rooted Teeth without SAP
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Pulpotomy
Partial pulpectomy Gross pulpal debridement Complete Pulpectomy Complete Endodontic Therapy |
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Treatment Options: Multi-Rooted Teeth with SAP
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Gross pulpal debridement
Complete pulpectomy Complete endodontic therapy |
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best treatment option for Multi-Rooted Teeth with SAP
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Complete Endodontic Therapy
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Necrotic Pulp Diagnoses with no Emergency Treatment Required
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Asymptomatic Apical Periodontitis
Chronic Apical Abscess |
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Necrotic Pulp Diagnoses with Emergency Treatment Required
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Symptomatic Apical Periodontitis
Acute Apical Abscess |
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Most difficult to treat
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Acute APical Abscess
spread from affected tooth a lot |
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Treatment Options Necrotic/SAP
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Gross pulpal debridement
Complete pulpectomy Complete Endodontic Therapy |
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A new study has shown that when two appointment treatment is done with _______________ ______________as an interappointment medicament there are fewer residual bacteria than when single appointment treatment is employed.
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calcium hydroxide
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Adjuncts to treatment
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Interappointment medicaments
Antibiotics Analgesics Incision and Drainage Occlusal Reduction Trephination |
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Characteristics: Interappointment Medicaments
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Do not reduce pain
Bacteriocidal Break down residual pulp tissue |
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Shown to be mutagenic and carcinogenic
Can be traced in other parts of the body Pungent (It stings the nostrils, but not in a good way) |
Formocresol
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Effective antibacterial
High pH Must be mixed with liquid to maximize antibacterial effect Must remain in tooth for a minimum of 1 week |
Calcium Hydroxide
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Interappointment Medicaments used in clinic
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Calcium Hydroxide
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Cacliym Hydroxide used in clinic
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Ultracal XS
35% Calcium Hydroxide 2% Barium Sulfate-can be seen on radiograph Methylcellulose |
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Do not use when treating vital teeth
Will NOT reduce pain |
antibiotics
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Indications for Antibiotics
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High fever
Malaise Cellulitis-acute apical abscess Trismus Persistent and progressive infections Immunologically compromised patients-contact pt physcian |
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A loading dose of _____ times the maintenance dose is recommended when treating orofacial infections
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2
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for necrotic tooth, what kind of antibiotic do you prescribe?
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its a TRICK, you dont, continue on
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Primary antibiotic and needs to be taken on an empty stomach
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Pen VK
500mg Q6h 7days |
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Used when allergic to penicillin
linked to collitis problems, pseudomembraneous collitis. |
Clindamycin
300mg, Q6h 7 days |
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Non Narcotics
Narcotics |
Analgesics
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Analgesics: Non narcotics
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NSAIDs
Acetaminophen |
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Analgesics: Narcotics
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Codeine
Hydrocodone Oxycodone |
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Flexible Analgesic Strategy
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Uses single analgesics or combination of analgesics to relieve pain
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Mild Pain
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400 to 600 mg Ibuprofen every 6 hours
650 mg Aspirin every 6 hours 650 mg Acetaminophen every 6 hours |
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Moderate Pain
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600 mg Ibuprofen and 650 mg Acetaminophen alternating every 3 hours (or taken together)
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Severe Pain
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600 mg Ibuprofen and 5-10 mg Hydrocodone/325 mg Acetaminophen alternating every 3 hours (or together)
325 mg Acetaminophen and 5-10 mg Hydrocodone/325 mg Acetaminophen every 6 hours |
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Tissue Decompression
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Incision and Drainage (ID)
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Incision and Drainage
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Incise swelling
Drain through tooth |
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Occlusal Reduction
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Reduce occlusion only if tooth is symptomatic to percussion
Studies are inconclusive |
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the surgical perforation of the cortical plate adjacent or apical to the symptomatic tooth
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Trephination
*studies have shown that it is not beneficial adjunct to reduce pain |
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Temporary Restorations
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Place cotton pellet (soaked in CHX) over the canals
Must be a minimum of 3.5 mm to seal tooth Never leave the tooth open |
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IRM
Cavit Triage |
Temporary Materials
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Easy to use- no mixing
Do not use in vital teeth (hydrophilic) |
Cavit
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Pink glass ionomer
Expensive |
Fuji Triage Glass Ionomer
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better with forces of mastication
the go to material |
IRM
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_______% of General Dentists had an anesthesia failure during restorative procedure in previous 5 days of practice
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90-Anesthesia problems are common
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_____% of the U.S. population experiences a toothache within a 6 month timeframe
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12
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Primary Dental Injections: Mandibular
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IAN
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Primary Dental Injections: Maxillary
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Infiltration
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Anesthesia Onset Times: IAN
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15min
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Anesthesia Onset Times: Maxillary Infiltration
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5min
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How can we tell if the patient is numb?
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We ask if the patient’s lip is numb.
We poke the gingiva with a sharp instrument *BOTH DONT WORK AS THEY ARE NOT TRUE PUPAL ANESTHESIA SIGNS, THEY INDICATE SOFT TISSUE ANESTHESIA* |
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ways they test pupal anesthesia in endo
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EPT
Cold |
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On a tooth with a healthy pulp an ___/____ EPT reading or a _______ cold response indicates a good level of pulpal anesthesia
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80/80
negative |
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___________ teeth are more difficult to anesthetize than ___________teeth.
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Mandibular
Maxaillary |
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Mandibular _________ are more difficult to anesthetize than mandibular __________ with an IAN block.
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anteriors
posteriors |
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80% of anesthesia problem in the __________
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mandible
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IAN Block: First Molar Success
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51-75%
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IAN Block: Central Incisor Success
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10-50%
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Whats the central core theory?
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Look in IAN there are 2 bundles. Core bundle in middle leads to the anteriors. It is easier to anesthesia the outer core than numbing the central core
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Of the following what can help improve the success rate of an IAN block?
Type of injection (Akinosi, Gow-Gates) Type of agent (Lidocaine, Articaine, etc.) Volume of agent (1.8ml vs. 3.6 ml) Concentration of epi (1/50k vs. 1/100k) Anesthesia of mylohyoid Placement (nerve stimulator, ultrasound) Bevel of Needle |
None, no real difference seen among them.
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Factors affecting anesthesia with pts who have Irreversible Pulpitis?
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Patient is anxious.
Inflammatory mediators reduce the excitability threshold of the nerves. Alteration of sodium channels decreases action of local anesthetic. *note IP pulps are inflammed |
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Indications for lack of pupal anesthesia
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a positive cold response
An EPT reading less than 80/80 |
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A normally non painful stimulus causes pain.
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allodynia
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Example of allodynia: A tooth with symptomatic apical periodontitis is painful to __________
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percussion
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A noxious stimulus produces more pain than it normally would
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Hyperalgesia
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Example of hyperalgesia: Elevated, prolonged cold response in a tooth with ____________ _____________
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irreversible pulpitis
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_____-_____% success IAN block for teeth with Irreversible Pulpitis
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15-25
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T/F: A negative cold response or 80/80 EPT will always indicate profound anesthesia.
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FALSE
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How do we solve the anesthesia problems associated with pts with irreversible pulpitis?
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Give supplemental injections
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Infiltration after IAN block of Md molars with these anesthesia increases success rate
|
4% Articaine with 1/100k Epi = 88% (58% IP)
2% Lidocaine with 1/100k Epi = 71% |
|
|
Labial and lingual infiltrations of 4% Arti with 1/100k epi(1 carpule each) achieves ______% anesthesia (healthy pulp)
|
98
|
|
|
Incisive Nerve Block at the Mental Foramen Works for __________ not _________
|
premolars
incisors |
|
|
Another term for Intraligamentary Injection
|
PDL ligament injection
|
|
|
Intraligamentary Injection Success rate: ____-____%
|
50-96, very variable
|
|
|
Needle placement for Intraligamentary
|
Needle in PDL and force liquid into it. More of a osseus resorption
|
|
|
T/F intraosseuous anesthesia can be used as a primary injection
|
False, its a supplemental one
|
|
|
intrasosseuous anesthesia is given with teeth with____
|
irreversible pulpitis
|
|
|
Intraosseous Anesthesia
|
2% Lidocaine with 1/100k Epi = 91%
3% Mepivacaine = 80% (98% with 3.6 ml) 4% Articaine with 1/100k Epi = 86% |
|
|
problem associated with intraosseuous anesthesia
|
67% had Increased Heart Rate with Epi
|
|
|
2 systems for intraosseous anesthesia
|
Stabident
X-tip System |
|
|
for stabident injection make sure it is in _______ gingiva
|
attached
|
|
|
stabident injections should be made _______ of the tooth to be ansesthitized
|
distal
|
|
|
made of trefani bur and godsleeve
|
x-tip
|
|
|
downside of x-tip
|
very aggressive and causes a ton of damage
|
|
|
The best option for achieving profound anesthesia on a tooth with irreversible pulpitis is the supplemental ____________ injection.
|
intraosseous
|
|
|
Ways to solve Maxillary Anesthesia Problems
|
1.Using an agent with vasoconstrictor will increase duration
2.Using 2 carpules of 2% Lidocaine with 1/100K will increase duration 3.Articaine works better than Lidocaine for lateral incisor (not 1st molar) |
|
|
Mx Anesthesia: V2 block works for ______ and not ______
|
molars
premolars |
|
|
Mx Anesthesia: Infraorbital block does not work for ______
|
incisors
|
|
|
Mx Anesthesia: PSA works for ___ molars not ____ molars
|
2nd
1st |
|
|
Maxillary teeth with Irreversible Pulpitis, ___% require supplemental intraosseous anesthesia
|
12
|
|
|
Considerations for Necrotic Teeth
|
Use block anesthesia where possible
Inject around a swelling (not into it) Do not use intraosseous technique |
