Set the Language

We weren't able to detect the audio language on your flashcards. Please select the correct language below.

Front

Back

Hint

Related Flashcards

Flashcards
»
Endodontics

Endodontics

by Kimberlyhaynes8811, Jul. 2007

Subjects: endodontics

Favorite

Add to folder

Flag

Shuffle
Toggle On

Toggle Off
Alphabetize
Toggle On

Toggle Off
Front First
Toggle On

Toggle Off
Both Sides
Toggle On

Toggle Off
Read
Toggle On

Toggle Off

Reading...

Front

Card Range To Study

through

Play button

Progress

1/222

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

222 Cards in this Set

Front
Back
3rd side (hint)

Cleaning Shaping and Obturation	Cleaning Shaping and Obturation	Cleaning Shaping and Obturation
Why do we clean, shape and obturate?	Bacteria break down the pulp and disease develops and persisits
Irreversible Inflammation is followed by _____. Infarction is followed by ____.	Irreversible Inflammation>>>Ischemia>>>Infarction>>>Necrosis>>>Periradicular spread of disease throug POE's
Teeth with LEO's heal ____% after extraction since all the infective contents of the root canal system are removed.	100%
What does LEO mean	Lesions of endodontic origin
Removal of existing or potential irritants from the root canal system. Ideally complete elimination Realistically: Significant reduction b/c of complex _____ and ____ would weaken the tooth.	Def of Cleaning and Debridment Realistically it is reduced b/c of complex CANAL anatomy and OVERENLARGMENT will weaken the tooth
How does one achieve cleaning and debridement? (2 ways)	Instruments: Mechanically scraping the walls Chemical Irrigants:flusing out debris and bacteriocidal action
What is shaping?	When one shapes the canal in a conical form form apical to coronal. The apical portion will be as small as possible and in its normal position. In order to do this correctly you want to remove an a uniform layer of dentin all around the canal
Shaping facilitates ___ and ____.	Cleaning and Obturating
How does shaping the canal in a conical fashion help in cleaning. (3 things)	Shaping the canal helps cleaning by Eliminating pulpal tissue and endotoxins Removing restrictive dentin Allowing effective volume of irrigation to work deeper and circulate
How does shaping the canal in a conical fashion help in obturation.	Removes canal contents Removes restrictive dentin Creates a smooth, tapered, and logical cavity preparation to the apex, which is good for obturation
What are the requirments for shaping? _____ canal Taper? How does one know when shaping is done?	Enlarge the canal Taper of .06 for warm vertical compaction Shaping is done when you can fit a NON standardized MED or FINE gutta percha cone to the working length
There are two objectives to cleaning and shaping. What are they?	Biological Mechanical
List the biological objectives of cleaning and shaping	Remove ALL pupal tissue Remove ALL bacteria Remove ALL endotoxins
List the Mechanical Objectives	Produce sufficient canal shapes -Achieves hydraulics required for 3D obturation -Gets a solid canal seal
Define Obturation	To stop up or close and opening
What are Shilder's Five Mechanical Objectives of cleaning and shaping? 1) To develop an continuous tapering ____. 2) To have the narrowest cross sectional diameter at the ___. 3) Maintain the orginal flow of the ____. 4) Do not transport the ___. 5)To keep the apical opening as ___as practical.	Continuous Tapering Cone Narrowest cross sectional diameter at the apex Maintain the original flow of the canal Do not transport the foramen Keep the apical foramen as small as practical. In Summary: Tapered Cone Smallest @ Apex Contour of Canal Dont Perforate the foramen Apical opening small
Name that instrument: Cylindrical Shape w/ Barbs and Hooks Removes paper points and cotton pellets Used to take out large amounts of vital pulp tissue	Broach
Name that instrument: Made from twisting triangular shafts Used for shaping the CORONAL and MIDDLE 1/3 of canal Used in a CLOCKWISE motion followed by a withdrawl stroke.	Reamer
Name that instrument: Made from twisting square/trianglar shafts -Up to size 30 Used to shape the APICAL and MIDDLE 1/3 of the canal Used in s short stroke up and down motion (watch winding) Recently hybrids of these instruments have been made. Produced by machining metal blanks with different cross sections tips and designs	Files
Iso Files are also known as ____ files. What is unique about these files. All have ___mm of cutting flute. All have a ____ mm taper Sizes range from 10-60. As it increases in size the tip diameter increases by ____mm In sizes from 60-140 the tip diameter increase ___ each file size.	Iso files have tips that are 1/100 of a mm. This corresponds to the file size. All have a 16mm cutting flute All have a 0.02 taper Increases in size= Increase in .05mm for 10-60 sizes Increases in size= Increase in .1mm for 60-140 sizes
State the advantage of the series 29 files.	Seriew 29 files -sizes 1-9 -increas 29% each file size -smaller files with increases in tip size= advantage
Name the Instrument: Milled from round steel wire w/ spirls milled into it Sharper edges Circumferential filing Used to retrieve gutta percha and separated instruments.	Hedstrom (H-type) files
Name instrument: Milled from round Ni-Ti blank All have .2 tip Taper varies from 6-12%mm	GT (greater taper) files
Name instrument: Engine Driven Latch Attachment Flame shaped Sizes 1-50, 2-70,3-90 and 4-110 ect Used for opening orifices, getting straight line access, and shaping the CORONAL 1/3 of the canals IMPORTANT: Brush against the walls AWAY from the furcation area.	Gates Gliddens
Name Instrument: Engine DRIVEN Latch attachment Parallel Sided* Used for opening orifices, gaining straight line access, and shaping the CORONAL 1/3 of canal Brush against wall AWAY from furcation.	Pesso Reamer
Name instrument: 56% nickel 44% titanium Have a MEMORY Engine driven Latch attachment Various tapers (2-12%) Various file designs (tips, angles, land etc) *Can be used to shape the CORONAL,MIDDLE,and in some cases the APICAL 1/3 of canal	Ni-Titanium
Ni Titanium is not a Panacea. What does this mean	It is NOT a cure all, remedy for all problems or to be used in EVERY situation although it is a great instrument
How do you use the Ni-Ti instrument RPM? Done in a ____ technique. Gentle "____" motion Flutes are ____ between each insertion Must NEVER be taken beyond ___. You can use these instruments with varing: Tip size/Keep Taper constant Taper/Keep Tip size constant or vary both simultaneously	RPM= 150-600 rpm Crown Down Technique Gentle Pecking Motion Flutes are cleaned between insertion Must NEVER be taken beyond the APEX
Irrigants MUST provide: Washing (Lavage) and dislodge debris Tissue ____. Antibacterial effects Lubricate Have Low/High surface tension? Remove ___ layer ___ toxicity	Irrigants must wash and dislodge debris provide tissue disolution antibacterial effects lubricate have a LOW surface tension remove smear layer have a low toxicity
Name 4 irrigants	Saline NaOCl (5.25% or 1/2 strength @ 37C) H2O2 (peroxide) Chlorhexidine Chelators (EDTA or citric acid) -removes metal ions from blood
What did the Abou-Raas study prove in 1987.	Irrigants can reach the apex if a 27-30 gauge needle is within 3-4 mm of the apex that has been opened to a size 30 file
Name a Dentin softening agent	17% EDTA or 10% citric acid Removes metal ions
Name a lubricant uses in the canal for less friction for the passage of files	EDTA + Glycerin (RC prep, Endo-Gel, ect)
Name a common medicament used in the canal? -Use when? -It is an ____. -Has a high ___	CaOH Use when RCT is NOT indicated It is an antibacterial High pH
Define Working Length	distance from the coronal reference point to a point where canal preparation and obturation should be terminated
Define Patency	Openness of the apical foramen apex should remain unblocked using a small file throughout the procedure
Define Recapitulation	Reinstrumentation of the canal withe the same series of instruments
Define Crown Down Technique	Instrumentation from the coronal to the apex. Larger instruments used first
Define Step Back Technique	Instrumentation of canal starting from apex towards the crown. Smaller instruments taken to working length and larger instruments are worked to shorter distances away from apex
Define Canal Transportation	Removal of canal wall structure on the OUTSIDE half of the apical curve
Apical Zipping?	Over instrumentation which creates a tear drop shape @ apex instead of round apex. Increases area for leakage and creates difficulty in obturation
Canal ledges?	Instrumentation in the same depth without reinstrumenting area and establishing patency.
Apical Perforation?	Created when a ledge is repeatly instrumented. go through apex
Stip perforations occur when a clinician doesnt brush ___ from the furca.	Brush AWAY from the furca
What is determined from a radiograph in the canal preparation.	Determine the # of roots and canals Orifice location Curvatures Root Angulation
Technique used for the proper access cavity is ____ generated _____ access Reduction of ____ interferences to prevent instrument separation.	Access Cavity Anatomically Determined Straight Line Access Reduce CORONAL interferences
What is Body Shape and Pre-Flaring? What is the advantage to doing this body shaping//preflaring?	Body Shape and Pre flaring confirms CORONAL patency and probes for curves, obstructions and extra canals Advantages: Volume Irrigants early Prevent extrusion of necrotic debris beyond the apex Better tactile sensation to detect apical constricture
Working Length Note the Average Morphology Radiographic Terminus Electronic _____ Tactile Paper Points T or F: Loss of WL is NOT expected after cleaning and shaping	Electoronic apex locators F: Loss of WL IS expected after cleaning and shapign
In 1976 Caldwell showed that a ___ mm WL loss in the MB roots of Max Molar	.35 WL loss in MAX molars
In 2002 Davis and Baumgartner demonstrated a WL loss is greater using what instruments.	Stainless Steel instruments lose WL more than Ni-T
How do you determine your MASTER APICAL FILE length? Apical opening must be @ least a size ___ file for adequate irrigation and obturation. -If less you MUST enlarge to a size 25	It is the largest binding file at the correct working length @ least a size 25 file
In 2002 75% of the 1st instruments that bound the canal walls were only contacting one wall. 25% did not contact any walls. T or F	TRUE
After WL and MAF has been determined the ___ provides resistance form	Deep Shape
What Hand instruments are used to shape the apical portion of the canal -Technique -Why are these good	Smaller Tapered Files -Use step back technique -Good: Flexible and can be precurved, good for difficult anatomy
How can you be successful at apical shaping. Instrumentation? Irrigation? Patency? Anatomy?	Recapitualate-Reinstrument Irrigate well Matain Patency Note anatomical constrictures
How do you blend the coronal and middle 1/3 of your canal preparation.	Brush canal walls with: Ni-Ti rotary Gates Glidden Precurve files and reamers
How do you remove the smear layer.	Use NaOCl rinse and EDTA rinse (1min)
What are the 4 objectives of obturation?	Completely seasl the entire length of the root canal system 3D fill Get as close to the CEJ as possible Use a core material and minimal amounts of biocompatible sealer
What material is used to obturate most commonly. What is this material composed of: 75% ____, 22%____ , and 3% _____ . Name the 2 phases and there corresponding temperatures. When does shrinkage occur	Core Material= Gutta Percha 75% Zinc Oxide 22% Gutta Percha 3% Wax w/ coloring agents and salts 2 crystalline phases -Beta phase @ 37C -Alpha phase @ 42-44 C Shrinkage occurs when going from alpha to beta phase
What does sealer do in the obturation step. (2)	Aid in the seal between the GP and the canal walls Lubricates
Do you condense in obturation.	NO condense means to make MORE dense! In obturation you compact- putting firmly together
What are the two methods of compaction of GP? Which one is used at BU	Warm Vertical -use @ BU Cold Lateral
Obturation steps 1) GP conefit 2)Radiographic confirmation 3) Cut back GP cone 4) Get 3 pluggers: Smallest must reach within ___ -____mm of the apex PASSIVELY 5) Dry canal w/ paper points 6) Mix Sealer 7) Coat GP with Sealer 8) Radiographic confirmation; Cone fit with sealer 9) Segmental Down Pack within ___to ___ mm of apex 10) Back fill to the level of the ___ using Obtura Gun or small GP cone	4) 4-5 mm passively 9) 4-5 mm 10)CEJ
Hutter's Lect	Hutter's Lect	Hutter's Lect
By volume DENTIN is: ____% Inorganic (Hydroxyappetite) ____% Organic (Collagen) _____% Fluid	45% Inorganic 33% Organic 22% Fluid
Name the 6 types of Dentin	Developmental Dentin (orthodentin): Has dentin tubules Mantle Dentin: first dentin formed. Stays dentin Pre Dentin: Matrix turns into dentin, always stays dentin Circumpulpal Dentin: surrounds dentin tubules Secondary Dentin Tertiary Dentin (Reparative Denitin): dentin layed down throughout the life of the tooth
Dentin Tubules make up ___ to ____ of the volume of dentin Mean # of tubules @ DEJ //Pulpal Surface The total tubular suface area @ DEJ//Pulpal Surface	20-30% of the volume is dentin tubules Mean # of tubules per square mm: 10-25,000 @ DEJ 30-52,000@ Pulpal Surface Tubular Surface Area @DEJ=1% @Pupal Surface=4%
Name the parts and functions of the dentin tubules	Peritubular Dentin: Highly calcified and mineralized Intertubular Dentin: between tubules Periodontoblastic Space: surrounds odontoplastic process which extends from odontoblast Lamina Limitins Dentinal Fluid
What are the 4 functions of the pulp?	Makes Dentin by havitn odontoblast Provides Nutrition to the tooth Provides Neuarl imput to the tooth Provides Defense to the tooth
You are a Doctor	You are a Doctor	You need to know this stuff
Pulp Morphology Predentin which will turn into dentin is ____ matrix and ___-____u is width Odontoblastic layer -How many layers thick -Contains ___ and ____. -What type of junctions.	Pre dentin: Uncalcified Matrix;20-25u in width Odontoblastic Layer -One cell layer thick -Has capillaries and nerve endings -Desmosomal Juctions
Pulp Morphology Cell poor region ____U in width Contains ___ and _____fibers. Cell Rich Zone: ____ and _____ cells	Cell Poor: -40 u thick -Capillaries and Unmylenated Nerve Fibers Cell Rich: Fibroblast and Undifferentiated Mesenchymal Cells
Pulp Morphology: Pulp Proper Core of the ____ which is made up of ___ and ___. Contains ___ and ____ Contains Cells (___, ___, ___, and ___.)	Pulp Proper Core of the CT -made up of collagen and ground substance -Contains nerves adn blood vessels -Contains fibroblast,macrophages, lymphocytes and plasma cells
Cell Free zone is always present unless tooth is doing what?	Actively producing dentin
The undifferentiated mesenchymal cells of the cell rich region become what types of cells	odontoblast to make 2ndary and tertiary dentin
Cells of the Pulp Lymphocytes and Plasma Cells are in the _____ region of the CORONAL PULP They are known as Immunologically Competent Cells	Subodontoblastic Region of the coronal pulp
Cells of the Pulp:(Odontoblast) -Fully Differentiated Cells -When they make dentin they use: Type ___ collagen, ___, and ____. What does the activity and location of the odontoblast mean.	Dentinogeneis -Type I collagen -Ground Substance -Hydroxyappetite crystals Coronally Located: Columnar in appearance// More active Apically located: Cuboidal appearance// less active Shape depends on function
Cells of the PULP: (Fibroblast) What is important about these cells What do they do? Unique about this cells appearance	IMPORTANT: Fibroblast are the most numerous cells of the PULP Function: Produce and degrade collagen and ground substance= alter matrix Unique appearance= Relatively an undifferentiated cell
Cells of the PULP: (Fibrocytes) -Mature ___. -# increases with ___. -Functions to ____	Fibrocytes -Mature fibroblast -Increase in # due to pulpal maturity -Functions to maintain collagen
Cells of the PULP: (Undifferentiated Mesenchymal Cells) -Found in the ___ zone -Source of ____. -Stem cells (pluripotent cells)	Undifferentiated Mesenchymal Cells -Found in cell rich zone -Source of Odontoblast
Other cells of the PULP Name them: -Fixed Macrophage, aids in the mononuclear phagocytic system -In odontoblastic layer -Source of Histamine, may or may not be in NON inflammed pulp	-Histocyte= macrophage -Odontoblastic layer= Class II APC's -Mast Cells= histamine, and noninflammed pulp
Ground Substance of Pulp ____ system _____ + water Matrix of CT and collagen Influences spread of ___.	Ground Substance Sol-Gel Colloidal System Proteoglycans + Water Influences the spread of inflammation
Fibers of the PULP. Name them and there location. # of fibers increase with what?	Type I: Dentin and Pulp Type II: Pulp Type IV: BM of BV # of fibers increases with AGE!
One fiber of particular importance is ___ which is in the walls of arterioles.	ELASTIN
All stimuli will be interperted as ___ to the pulp	PAIN
Afferent Nerve Fibers are also called___. Pain is described as what? Threshold is low/high? Neural pathway is where? How long does it take for these fiber to develop in the oral cavity Stimulated by ___ and ___.	AKA: Myelinated A Delta Fibers Pain is sharp and pricking Low threshold of stimulation Neural pathway is athe the central area of the pulp Not completed in development until 5 years of age Stimulated by EPT and COLD
Describe the Neural Pathway of the Mylenated A delta fibers what important happens in the -plexus of raschkow -odontoblastic layer -dentin	1) Enter through foramen 2)Goes through plexus of raschkow -Loses Mylein Sheath 3) Cell free zone 4) Odontoblastic layer -New plexus forms 5)Predentin 6)Dentin -Loss of Shwann Cell Coating here
Unmeylenated C fibers give what types of sensation of pain? Threshold? Where is the Neural pathway located? Do the Unmylenated C Afferent fiber branch in dentin. Which has more C or A	Burning, Aching, Throbbing PAIN HIGH threshold!!!! Neural pathway located with A delta fibers bundles througout BODY of pulp No branching in dentin C is more numerous than A delta fibers
AFFERENT Unmylenated C Fibers are known as true ____ nerve fibers. They resist ____ and are stimulated by ____ liquids	C fibers -True Nociceptive Fibers -Resist Necrosis -Stimulated by HOT liquids
EFFERENT Unmylenated C fibers (going from brain) Have ____ganglionic sympathetic nerve fibers that VASOcontrict Involved in dentin formation Are cholinergic parasympathetic fibers in the pulp?	Postganglionic SYMPathetic nerve fibers that vasocontrict NO, cholinergiv parasympathetic fibers in the pulp thus NO VASODialation
Pulpal Sensitivity	Pulpal Sensitivity	Pulpal Sensitivity
How many theories exsists for pulpal sensitivity (4).	Direct Stimulation Transduction Hydrodynamic Modulation
What is Modulation?	Tissue destruction stimulates pain Depending on the pain type depends on the nerve fibers stimulated If pain continues then that is the basis for rct
What is Brannstroms Hydrodynamic Theory?	Rapid movment of dentin tubules stimulate the A delta nerve fibers in the odontoblastic layer of the pulp Mechano-stimulation
In Brannstrom's Theory Dentinal tubules function as ____ tubes -Heat ____the tubes and fluid move inward to stimulate the free nerve endings of the A delta fibers Cold ____ the dentinal tubules and fluid move outward to stimulate the A delta fibers Are C fibers activated? Is Pulp tissue irreversible damagedat this point. -What does this explain?	In Brannstrom's Theory Dentinal Tubules function as capillary tubes Heat expands tubules=fluid moves inward=stim A delta fiber nerve endings Cold=contracts tubules= fluid moves outward and A delta fibers are stimulated C fiber are NOT activated thus Pain does not linger Pulp tissue is NOT irreversibly damaged- this explains the hypersensitivity of dentin
Deep Pulpal Pain This is Pulpal Inflammation. When a patient is at this state the ____ theory is beleived to hold true. Tissue destruction has stimulated pain. ____ substances are released ____ fibers are stimulated Pain lingers and is spontaenous.	Modulation Theory -Alogenic Substances released -C fibers stimulated Lingering spontaneous pain
What are proprioceptive nerve fibers. Are they in the pulp?	Proprioceptive Nerve fibers are what help to localize pain. They are in teh PDL...NOT the pulp
Vascular Supply of Pulp consists of what 4 components What is NOT present	Arterioles Capillaries Venules Arteriovenous Anastomoses NO ARTERIES// VEINS
What is the diameter of an arteriole Vasoconstriction is controlled by ____ ganglionic ______ nerve fibers Is there vasodialatory control?	Arteriole Diameter 10-100u Vasoconstriction via POSTganglionic sympatheic fibers There is NO Vasodialation in the pulp
Capillaries in the pulp are termed ____. They are in the _____zone in an area called the ______plexus	Capillaries are Fenestrated Cell Free Zoned Subodontoblastic Plexus
Venules have a max diameter of ____u. What happens when subjected to too much pressur.	Max 200 U Collapse when subjected to increase pulpal intersitial pressure
The ____-____ connection is a low compliant system. Since there is no room for expansion b/c of surrounding dentin ____ pressure is maintained.	Arteriole-Artery connection maintains hydrostatic pressure
Arteriovenous Anastomoses Venules are ____U in diameter This is a direct connencetion between arterioles and venules 2 Functions: -Regulates _____ -Shuts ____ drung inflammation in pulp	10u thick -Regulates Blood Flow -Shunt Blood during inflammation process
Are lympatics in the pulp?	Dont Know-Controversal if so they would be in the pulpal tissues
Pulpal Pathophysiology	Pulpal Pathophysiology	Pulpal Pathoplysiology
What makes the pulp susceptible to irreversible injury: ____ compliance system. Poor _____. Pulpal ____. Abundant ____.	Low compliant system (surrounded by dentin) Poor collateral circulation Pulpal degeneration Abundant Oral Bacteria
Since there is a direct connection betwwen the dentin and the pulp, if caries gets into the dentin what happens to the pulp.	It reacts to the caries products (bacterial products) Endotoxins Immune Complexes
What is the initial defense of dentin to protect the pulp from injury.	Sclerotic Dentin (Hardening of the dentin) via laying down increased amounts of peritubular dentin This is highly mineralized/initial defense against low grade carious lesions
What is a dead tract	response to and acute carious lesion -loss of odontoblastic processes -which is an OPEN pathway for infection to the pulp
What is reparative dentin (aka tertiary dentin) What is a calciotraumatic line?	reparative dentin tries to replace the odontoblast. It is less tubular and more permeable than primary dentin Calciotraumatic line= line that is seen from where the odontoblastic layer was originally
So now the pulp is infected with bacteria. What is the 1st response of the pulp? -Chronic/Acute? -Cells? -Collagen? -BV	1st response in a CHRONIC one -lymphocytes, macrophages and plasma cell try to ward off infection -collagen is deposited -proliferation of blood vessels
Is pulp in a reversible state during the chronic phase of pulpal inflammation.	It can be at a reversible state...YES
Bacteria gets deeper into the pulp and then a ____ response is illicited. Vascular changes like ____ occur Cells? Fluid? Pressure? Fibers stimulated?	Acute Response -Vasodialation/Increase permeability of BV -PMN's -Increase in intrapulpal fluid (edema) Increase in intrapulpal pressure Stimulation of C fibers
What is happening to the pulpal tissue during the inflammatory process	Tissue is being destructed MICRO Abcess are forming -the pulps way of trying to wall off infection Venules eventually collapse due to pressure Ischemia (restricted blood supply) followed by necrosis (death of cells/tissue) Complete necrosis of pulp C-fibers may still be viable This is
Now we talked about many stages during the pulpal inflammatory process. Lets give them names. (3 ways to classify pulpal inflammation)	Reversible Pulpitis Irreversible Pulpitis Complete Necrosis
Reversible Pulpitis -Localized/Generalized? -Localized/Generalized increase in intrapulpal pressure? -Threshold for ____fibers is LOWERED!!! This is known as _____. There is an exaggerated response to ____ stimuli but it does not linger Is there perm pulpal damage? How do you tx:	Reversible Pulpitis -Localized -Localized intrapulpal pressures -Threshold for A delta fibers is LOWERED. Called Hyperalgesia (barely touch-feel pain) -Exaggerated response to thermal stimuli NO perm pulp damage Tx: Take care of etiology. Take care of caries
Irreversible Pulpits ____spread of inflammation Threshold for ___ and ___ fibers is LOWERED!!! Pain lingers after ____ stimulus. Pain is described as ____, ___ and ____. Is there pulp damage? How do you tx	Circumferential spread of inflammation Threshold for A and C delta fibers is LOWERED!!! Pain lingers with THERMAL stimulus Spontaneous, Dull, Aching Pain Pulp is irreversibly damaged Tx:Pulpectomy -remove pulp
Complete Pulpal Necrosis Symptoms? Response to vitality tests? Necrosis of fibers? How do you tx	Complete Necrosis of Pulp May/May not be symptomatic NO response to vitality tests All A delta fibers are GONE...DEAD!!! C delta fibers may still be viable Tx: RCT
Periradicular Pathophysiology	Periradicular Pathophysiology	Periradicular Pathophysiology
Periradicular tissues have a ____ communication with the pulpal tissue. Thus if the pulp gets infected to a certain degree the periradicular tissues will also be affected. Note: Inflammation _____ infection. In the periradicular tissues there is a _____ cirulation ___bone allows for drainage of edematous fluids _____ fibers are present.	Direct Communication Inflammation PROCEEDS INFECTION Cancellous Bone allows for the drainage of the edematous fluids from the pulp Proprioceptive fibers are present
There are 7 classifications of periradicular disease. Name them	Acute Periradicular Periodontitis Acute Periradicular Abcess Chronic Periradicular Periodontitis Chronic Suppurative Periradicular Periodontitis Phoneix Abcess Chronic Periradicular Periodontitis w/ Symptoms Focal Sclerosing Osteomylelitis (condensing osteitis)
Acute Periradicular Periodontitis This is an acute response in the ____. Due to ____ or ____. Pt will complain about ____ teeth or when doing a ____ test. At this point you know that the _____ fibers have been stimulated so the pt can localize pain Radiographically you should see as widened ____ and a brean in the ____.	Acute Response in the PDL -due to pulpal disease (pathoses) or occlusal trauma Pt complains about occluding teeth and during percussion test (sensitive) Proprioceptive fibers activated Radiographically= Widened PDL//break in the lamina dura
Acute Periradicular Abcesss This let you know that there is an ____ in the periradicular tisses. -The host is trying to ward off the infection so it forms an abcess. This occurs in the ____phase of the infection. It will have a _____ exudate What types of swelling or systemic symptoms will you note? Radiographically I will see	Infection in Periradicular tissue -Acute phase -Purulent Exudate Systemic Symptoms: Cellulitis, Fascial Space Involvement Radiographically: Widened PDL and break in lamina dura
Chronic Periradicular Periodontitis ____grade, long standing lesion. This is the body's way of trying to wall off infection from the root canal system. Clinically the pt will be _____. On a radiograph you will see a _____associated with the periradicular area of the tooth b/c of a _____ or _____.	Chronic Periradicular Periodontitis Low grade, long standing lesion Asymptomatic pt Radiographically: Radiolucency associatd with the root of the tooth b/c of a periradicular granuloma or cyst
Chronic Periradicular Periodontitis cont What is the granulomatous tissue composed of? What is the periradicular cyst?	Macrophages Lympocytes Plasma Cells Fibrous Tissue Capsule with Increased vascularity Periradicular Cyst -3D epithelial lined cavity with fluid -lumen may or may not communicated with apical foramen -Stim of epi rests of malassez with/in granuloma
Chronic Suppurative Periradicular Periodontitis This occurs when a chronic periradicular lesion has established ____ in the ___ or ____. ____is present	Established Drainage in cortical plate or peridontal tissues Sinus tract present
Phoenix Abcess This is an exacerbation of the _____ lesion. _____ are more virulent _____ is decreased Clinically: Acute Periradicular Abcess Radiographically it is ____.	Chronic Periradicular Periodontitis -Virulent Bacteria -Decreased Host response Radiograhically it will lok like Chronic periradicular peridontitis
Chronic Periradicular Periodontitis w/ Symptoms Occurs when chronic lesion becomes ____. There will be an increase in _____. Clinically the pt will have symptoms Radiographically there will be what?	CPPS Chronic lesion becomes acute -increase in PMN's Radiographically= RL in periradicular area
Focal Sclerosing Osteomyelitis this is ____ grade pulpal inflammation host resistance is ____. Histology: Mild inflammatory response leads to an _____ in bone deposition clincially pt is symptomatic or asymptomatic? radiographically there will be an increase in ____ and ____ on the radiograph.	Focal Sclerosing Osteomyelitis (local hardening of inflammation in the bone) Low GRADE pulpal inflammation Host resistance is HIGH Histology: Mild inflammation--> INCREASE in bone deposition Clinically pt is Asymptomatic Radiographically---> increased bone density and trabeculations
Classify Pulpal Pathoses	Reversible Irreversible Complete Necrosis
Classify the Periradicular Pathoses	Acute PR Peridontits Acute PR Abcesss Chronic PR Periodontits Chronic Supparative PR Periodontitis Phoneix Abcess Chronic PR Periodontits w/ Symptoms Focal Sclerosing Osteomyelitis (AKA condensing osteitis)
What info do you need in order to make the right dx	Dental History Clinical Exam Radiographic Exam
There are 2 dx we are concerned with,...what are they.	Pulp Dx PR Dx
Pathophysiology of _____. Hyperemia (sensitive to light touch) Transient vasodialation Increased Hydrostatic pressure in the pulp reversible if the etiology of inflammatory process is removed.	Reversible Pulpitis
Dental History of ____. NO prior history of pain Sharp, Hyper-response to thermal change (cold/hot) -Pain DOES NOT linger after stimulus removal Pain is NOT spontaneous -it has to be provoked May be a restoration just placed on tooth	Reversible Pulpitis
Clinical Examine of RP Recently placed restoration will have____. Carious Lesion may be present Restoration is defective Cervical ____ /abrasion	Clincal Exam of RP Wear Facets Cervical Erosion/Abrasion
RP Radiographically PDL? Lamina Dura? Lesion? Restoration?	PDL// Lamina Dura= WNL May see carious lesion or deep restoration w/ without base
How do you test for RP	EPT (electronic pulp test) - + Thermal Test -Hypersensitive to pain but when stimulus remove pain stops Percussion Test -Negative Palpation -Negative
What is the emergency tx for RP	Adjust occlusion Remove restoration -place temp w/ zoe
Irreversible Pulpitis (IP) Known as ____ spread of infection Acute/Chronic response of pulp? Exudate? Pressure? -Compliance System? Is it reversible	IP Known as circumferential spread of infection -Acute Response -exudate has NO escape -increased pressure due to low compliance system - NOT reversible
Dental History of IP	Pt is going to say they are having spontaneous pain (comes and goes) remembers having pain episodes before but not to this degree Pain response is exaggerated to cold, hot, sweet BUT pain lingers after stimulus is removed
Clincial Exam of IP pt. (see 3 things)	lg restoration CLOSE to pulp defective restoration carious lesion by pulp
Radiographic Exam of IP pt.	Deep restoration w/ or without base carious lesion PDL WNL or larger may see break in lamina dura
How do you test for IP	EPT: Positive Thermal:Hyper response= lingers Percussion= Neg/Positive depends if Periradicular tissue is inflammed Palpation +/- depending on if periradicular tissue is inflammed
Emergency TX of IP: Pulpotomy= Use ____ or if immature tooth you would do an _____ b/c of open apex Pulpectomy? Pain Killers given?	Non surgical RCT Pulpotomy: Use FORMOCRESOL -immature tooth= apexogenesis Pulpectomy -Anesthesia -CaOH (medication) -Seal access cavity Pain Killers= NSAIDs
What if IP is asymptomatic...What does this mean? Name the 2 situations that can occur due to this?	Asymptomatic means that exudate escaped Hyperplastic Pulpitis (Pulp Polyp) or Internal Resorption
Necrotic Pulp -due to ____, ____, or ____. -can be the result if etiology is not removed in RP -it is the result of circumferential spread of inflammation	Due to caries, trauma, pdd
What is the dental history of necrotic pulp	History of trauma, caries, pdd had pain presently asymptomatic no pain when provoked or stimulated
Necrotic Pulp clinically	Carious lesion close to pulp Lg restoration close to pulp Tooth Discoloration PDD
NP Radiographic Exam -carious lesion approximates or exposes pulp -deep restorations within proximity of pulp PDL space? Lamina Dura	PDL WNL or widened slightly May see break in lamina dura
How do you test for NP?	EPT: NEG Thermal: NEG Percussion: NEG/ + if pr tissue is inflammed Palpation: NEG/ + if pr tissue is inflammed
Tooth with a hx of previous rct. -Pulpotomy -Pulpectomy -Non surgical RCT -Surgical RCT	Pulpless or Previous Root Canal Tx
Periradicular Dx	Periradicular Dx	Periradicular Dx
Primary Acute Periradicular Periodontitis -Inflammation in pulp has extended through apical foramen into PR area	T or F: T
Dental History of Primary Acute Periradicular Periodonitis	Feels like tooth is HIGHER than adjacent teeth -Increased pain when chewing -may/may not have increased pain with temp change -may/may not have spontaneous and/or continuous pain -past hx of pain
Clincially someone with Acute Periradicular Peridontitis will have	Caries near pulp Lg restoration near pulp Tooth discoloration PDD Fractured tooth
Radiographically PDL? LAMINA DURA?	Caries Restoration PDL WNL or slightly widened YOU WILL SEE A BREAK IN THE LAMINA DURA
Dx APP:	EPT: +/no response Thermal: +/no response Percussion: POSITIVE Palpation: POSITIVE
Emergency TX:	NO Pulpotomy Pulpectomy -anesthesia -cleanse root canal system -CaOH in canal Seal Access Cavity -Occlusal Adjustment Pain Killer- NSAID
Secondary Acute PR Peridontitis occurs when the pt has had a ____ in the past 1-2 days Pt might say? Pain?	RCT in past 1-2 days Pain is spontaneous/cont -pain in chewing, percussion, palpation Feels like tooth is higher than the others Feels like pressure is building up in my jaws (swelling)
Emergency Tx for secondary acute PR peridontitis	occlusal adjustment is there another canal place a corticosteroid paste seal access cavity put a hole in the buccal or cortical plates (trephination)
Acute PR Abcess can occur b/c of 1 of three things It is known as a TRUE infection	Advances Acute PR periodontitis Decreased host resistance Increase virulence of bacteria
Dental Hx of Acute PR Abcess	History of Pain Pain may/may not be present currently Swelling is present Fever, lymphodenopathy, sweating, chills, GI disturbance. Pt feel and look sick
Acute PR Abcess Clinically Examination	Extraoral/Intraoral swelling Tooth mobilty Carious lesion Lg Restoration Discolored teeth -Hx of Trauma
Radiographic Exam of Acute PR abcess PDL Lamina Dura	PDL=WNL or slightly bigger Lamina Dura= BREAK
Acute PR Abcess Dx Test	EPT: - Thermal:- Percussion: + Palpation: +
When managing odontogenic infections you must consider what 3 things	pt's health anatomical factors -where is the infection in relation to B/L plates -what is the closest muscle attachment microbial factors
What is your intial tx of odontogenic infections dependent on	Dependent on initial dx taken from your history taking, clinical exam and lab data It is also based on the origin of the infection
Goals of Tx of Bone infections when in the surgical phase (incise/drain and decompress)	Decrease the # of bacteria Decrease pressure ---> thus alleviates pain, trismus and improves circulation in the area Prevent the spread of infection any further Alter Oxidation/Reduction potential in tissue Acclerates healing
What is used to decontaminate the site in the surgical phase Anesthesia given= regional blocks and infiltrations *avoid needle track infections	Betadine Scrub
The incision - In ____ tissue -Most DEPENDENT area -___-____ in length -Rule of "___"	In healthy tissue -1/2-3/4 in -Rule of index finger
Blunt dissection is done with ____.	Hemostate curved -open to separate tissue -extend into adjacent spaces
Insert Drain made of _____ tubing (H/T shapes) Suture to healthy tissue Allow to stay in for ___ days	Sterile Penrose Tubing Stays in for 2-7 days
Can you do endo while drain is in place	YES
Remove drain ___hrs after cleaning and shaping root canal system or After infection resolves	24 hrs
Antibiotic Therapy	Antibiotic Therapy	Antibiotic Therapy
Indications for Anti-B therapy (4).	Host Resistance not doing well or is being tested Systemic is involved Fascial space involvement Inadequate surgical drainage
Guidelines for Anti-B	Want Anti B in anerobic spectrum lg dose= short period collect specimen BEFORE initiating Anti-B therapy Utilize gram stain to select anti- b if you can
If no gram stain or culture sensitive test done which anti- b should you use	Penicillin
Penicillin is the 1st drug of choice b/c it kills ____ and _____. Dosage? -Loading dose -After that?	Gram +/- aerobic cocci Anerobic bacteria (most) Dosage: 1-2 gram loading dose 500 mg every 6 hrs for 5-7 days
What is the 2nd drug of choice use if allergic to penicillin/ no improvement in pt condition within 48 hrs What does it kill?(2) Dose? -Loading and then after that? If on this for too long a pt can get what?	Clindamycin (cleocin) Kills -Gram + Aerobic Streptococci -Gram -Anerobic Rods Dose: -Loading: 600 mg -150-300 mg every 6 hrs for 5-7 days Psuedomembranous Colitis
What is Pseudomembranous Colitis	Overgrowth of clostridium difficil (gram + spore forming anerobic rod) -growth is inhibited by lactobacillus, porphymonas and peptostreptococci Pt at risk: elderly, immunocompromised
Pseudomembranous Colitis is most often associated with _____>_____>_____. C difficil produces what 2 toxins	Cephalosporin>Ampicillin>Clindamycin 2 toxins=Toxin A (enterotoxin) and Toxin B (cytotoxin)
Give the 3 forms of Pseudomembranous colits	1) Anti B associated -diarrhea w/out colitis -no overgrowth of c difficil -diarrhea develops in 3-10% of adults when taking anti-b 2) Anti- B associated without pseudomembrane -overgrowth of c difficil -has colits -no toxins 3)Anti-B associated with prod of pseudomembrane
Metrodiazole (AKA: Flagyl) Absorbed Where? Excreted Where? Mode of Action? -How? Adverse effects? What does it kill? -which ones are more resistant What is the dosage	Absorbed in the mouth Excreted in the kidney Bacteiocidal -via disrupting DNA Adverse affects:Antabuse effect Kills -ALL ANEROBIC Rods (-) -Anerobic (+) cocci -Faculative aerobes more resistant dosage 500 mg every 6 hrs for 5-7 days
Anti B effect oral contraceptives	T
What is the NSAID of choice Dosage? -pre-op -after that?	Ibuprofen (motrin) 600 mg tablets -1 tab pre-op 1 hr -1 tab every 6 hrs
Applied Heat -Warm mouth rinse -Extraoral heat compressors (moist) Why use it: How often	Aid in body defenses -vasodialation -increases circulation into infected area -removal or tissue products -increased inflammatory cells into infected area NOT USED to regulate localized infection How often:20-30 min
Fluids -which one -how much	8-10 glasses of gatorade per day
Chronic PR Peridontitis is perapical inflammation / infection resulting in ____ Lesion is of Endodontic Origin Histologic Dx of Granuloma or cyst	bone resorption
Dental Hx of Chronic PR Peridontitis -Symptomatic? -History of pain? -Restoration, caries, or trauma=YES Clinically -Restoration, caries, trauma Radiographic exam -? Dx Test?	No symptoms History of Pain Radiographically= PR radiolucency
Chronic Supparative Periodontitis must have an ____.	Intraoral sinus tract
Phoenix abcess is a _____ that becomes acute periradicular abscess	Chronic PR Periodontitis that becomes and acute pr abscess
Emergency tx for Phoenix Abscess	Managed the same as acute pr abscess
Chronic PR Periodontitis w/ symptoms Symptoms are? Emergency tx	Spontaneous Pain Pain on chewing and brushing emergency tx: rct -pulpectomy -caOH -seal -NSAID's
Chronic Focal Sclerosisng Osteomyelitis AKA? Low grade pulpal inflammation w/ ___ host resistance clinically pt is symptomatic or asymptomatic	AKA: Condensing Osteitis -increased host response -pt asymptomatic
1982 Abou-Rass stated that the ability of the pult ot recover depends on what 6 things	Type of injury Duration of injury thickness of remaining dentin age of tooth host factors past trauma
What should you consider when selecting a pt for endo	can this tooth be endo tx are the canals negotiable can the tooth be isolated non surgical/surgical
How do you know if a tooth should be endodontically tx	Is the tooth restorable Periodontal status Strategic value of tooth Health of pt Motivation of pt
What is SOAP	Subjective Findings Objective Findings Assessment (Dx) Plan of tx -endo -perio -pros
Which are mylenated and which are not: A//C What are the other fiber in the tooth.	A delta fiber=mylenated C delta fibers=unmylenated Proprioceptive fiber (in the PDL)
When trying to get the Hx of pain from the pt ask: -When was the problem first noticed? -Describe Pain? -Duration of pain? -Aggressive Factors to consider? -Any swelling? Give the translation for these questions	Translation: How long has it been going on Is it local, diffuse, unsure// is it sharp/dull, throbbing when it starts how long does it last (constent/intermitant)
Sharp Pain is from ___ delta fibers Delayed (crescendo), throbbing (deep tissue), or a pulsating/pounding pain is from _____ delta fiber stimulatin	A delta fibers=Sharp C delta= delayed, throbbing, pounding, pulsating
T or F: Pain is referred across the midline	FALSE
When you ask question like: Is it hurting now? Did it hurt yesterday? Have you ever noticed the pain before Once it starts how long does it last Does it come and go or is it constant? You are asking these questions to find out the ____ of pain	Duration
What the heck are aggresive factors..? You would ask questions like?	Is it provoked by stimulus What causes the pain (hot, cold, sweet, biting) Does it continue after stim is removed Does posture increase pain
During the clinical exam you are looking for what extraorally//intraorally?	Extraoral -swellings of the fascial spaces -Lymphodenopathy -Fever Intraoral -soft// hard tissue -swelling -sinus tract -discoloration -caries -trauma -fractures
Radiographic Exam -good angulation -Use ___ Bw's for posterior teeth *Take your own films. Do not rely on someone elses	Vertical BW's for posterior teeth
What is the reason we do dx test?	You must reproduce the symptoms in office
EPT -Isolate teeth with ___ -Put topical gel when using electrolyte -DONT place tip below ____. -Must test adjacent teeth	cotton roll isolation DO NOT place below cervical 1/3
Cold Test -Use ____. -Spray on q-tip -place on ___ surface of tooth	Endo ice -Place on B surface of tooth
What can I gather from teh pulp test	If pt feels cold: Pulp is vital/ if not= necrotic if painful to pt: tooth is localized can determine extent of disease: does pain linger---->reversible pulpitis /or ache after removal of stimulus---> Irreversible pulpitis
Heat Test -Use flat instrument -Heat ___ -Vaseline teeth -Place in ____ of tooth	Heat Gutta percha with touch n- heat place in coronal 2/3
Heat test is only used to confirm a dx of ______ from dental history	dx of pulpitis from dental history
How do you do a Thermo-Test?	Use hot/cold water
Percussion	Gentle tapping not banging of tooth
True percussion sensitivity is extremely well localized and very ____. So____ first. Tip: leave suspected tooth last ___ is also acutely tender to percussion BUT a PERIO abscess the tooth ALWAYS Test ___ usually with generalized condition elsewhere.	Painful- so palpate first Acute Periodontal Abcess Perio test vital
How do you decide if Perio/Endo?	EPT Thermo Probing Tracing the lesion from sinus tract using GP
Cracked Tooth Syndrome -Typical Symptoms? -Is pain constant? -Is it hard to localize? Multiple attempt to dx b/c non reproducible response to the test: Which one	Hot/Cold Sensitive Hurts on biting Pain is intermittant Hard to localize=YES EPT, Thermo, Percussion
Dx the cracked tooth chief complaint What do you do?	Sensitivity to both hot and cold Sharp pain on release of biting pressure Identify tooth w/ cotton roll test Remove restoration and chase crack using methylene blue and magnification
Tx of Cracked Tooth	Enamel Abrafaction- No Tx Incomplete Fracture of enamel/dentin: remove restoration, stain, crown restoration 3)Incomplete:Fracture of enamel and dentin into pulp-RCT with crown 4)Split (cleaved) toot-fracture of enamel and dentin into pulp chamber- ext.