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46 Cards in this Set
- Front
- Back
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SOAP
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Subjective information
Objective findings Assessment Plan of treatment |
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Reversible pulpitis
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Non lingering to thermal tests and non spontaneous
- Happens after restoration for a week and goes away |
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Symptomatic Irreversible pulpitis
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Lingering pain after stimulus like thermal test and spontaneous. Usually severe
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Asymptomatic irreversible pulpitis
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No clinical symptoms and inflammation of the pulp caused by caries, caries excavation, trauma, that causes pulp exposure in the chair
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Pulpal diagnosis
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Reversible pulpitis
Symptomatic Irreversible pulpitis Asymptomatic Irreversible pulpitis Necrotic pulp - No response to thermal or electrical stimuli Previous root canal therapy - Canals are obturated and normally have no response Previously initiated therapy - Partial endodontic therapy like pulpotomy or pulpectomy. Usually have no response |
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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 Condensing Osteitis Focal osteopetrosis/Periapical osteosclerosis |
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Symptomatic apical periodontits
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Pain to biting and percussion.
Have symptoms but may or may not have swelling or Periapical radiolucency |
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Asymptomatic apical periodontits
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Cannot elicit pain or altered sensation
However, must have apical radiolucency. |
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Acute apical abscess
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Localized swelling, pain, and pus formation.
- Tender to pressure and may have fever and lymphadenopathy. - Possible radiolucency |
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Chronic apical abscess
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Minimal or no pain since pus drains from sinus tract
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Functions of pulp
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- Formation of dentin
- Sensation - First line of defense to injuries and infection of dentin |
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Components of pulp
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Cells
Fibers and glycoproteins Ground substances Blood vessels, nerves, and lymphatics |
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Movements of tubules
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Heat makes fluid and odontoblastic process move inward
Tactile, evaporation and osmotic makes it go outward |
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Pulpal axonal reflex due to dentin stimulation
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Release Substance P and CGRP which may release inflammatory agents and increase pulp pressure
- Without bacterial infection, vascular changes could be resolved |
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Routes of root canal infection
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Caries
Trauma induced fractures Restorative procedures Periodontal scaling and root planning |
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Pathogenecity vs Virulence
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Pathogenecity is the ability of microbe to cause disease
Virulence denotes degree of pathogenicity |
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Collagen in dental pulp
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Concentration varies between species but is 32% in humans
- Higher content in the middle and apical region - Total collagen decreases with age - High levels of type III collagen |
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A-delta fibers
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- Lower threashold, so involved in fast and sharp pain
- Stimulated by hydrodynamic stimuli - Sensitive to ischemia |
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C fibers
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Higher threashold and involved in slow, dull pain
- Stimulated by direct pulp damage - Sensitive to anesthetics |
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Dentinal tubules
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Largest diameter at near the pulp - 2.5 nanometer
Smallest at the periphery - 0.9nanometer Smallest tubule still compatible with diameter of most oral bacterial species which ranges from 0.2 to 0.7 nanometer |
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Delay of bacteria invasion
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Outward movement of dentinal fluid and tubular content
Dentinal sclerosis beneath a carious lesion Tertiary dentin |
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Primary vs Secondary infection
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Primary infection - Caused by microorganisms that initially invade and colonize necrotic pulp tissue
Secondary infection - Caused by microorganisms not present in the primary infection but introduced at some time after professional intervention Most part clinically indistinguishable, but if symptoms arise after professional intervention in a previously uninfected tooth, its typically a secondary infection |
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Most common bacteria found in failing root canals
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Enterococcus Faecalis
Other include: Fusobacterium Nucleatum Prevotella species Actinomyces species Lactobacilli |
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Sources of nutrients for bacteria
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- Necrotic pulp tissue
- Proteins and glycoproteins from tissue fluids and exudate that seep into root canal system via foramens - Components of saliva that may coronally penetrate into the root canal - Products of metabolism from other bacteria |
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Key points
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Instruments shape, Irrigants clean
Endodontic therapy is not complete until the tooth is restored to function |
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Diagnostic measures to locate canals
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- Multiple pretreatment radiographs
- Examination of pulp chamber floor with a sharp endo explorer - Staining chamber floor with methylene blue dye - Performing the sodium hypochlorite "champagne bubble" test |
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Anterior access
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Burr should be directed perpendicular to the lingual surface
- Initial external outline form should be cut with a #2 or 4 round bur or a tapered fissure bur to penetrate through enamel and into dentin - Access should be 1/2 to 3/4 the size of the projected final size of access cavity - Penetrate pulp floor with same round or tapered bur, and frequently, a drop in effect is felt - Change the bur from perpendicular to parallel to the long axis |
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Removal of lingual shoulder and coronal flaring
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Usually a lingual shelf of dentin that extends from the cingulum to a point 2mm apical to the orifice
- Use a safety tipped bur or a Gates-Glidden bur inclined to the lingual to slope the shoulder |
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Final position of the incisal wall
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Determined by complete removal of pulp horns and straight line access
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Maxillary central
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Root canal at CEJ is triangular in younger teeth and oval in older teeth
- External access outline form is a rounded triangle with its base at the incisal |
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Maxillary lateral
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Pulp chamber outline form is similar to central and is smaller and has two or no pulp horns
- External access may be a rounded triangle or oval depending on the prominence of the mesial and distal pulp horns |
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Maxillary canine
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Similar to incisors but they are wider Buccolingually than Mesiodistally
- No pulp horns - External outline is oval or slot shaped |
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Mandibular central and lateral
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Must eliminate lingual shoulder to allow direct-line access because it may conceal a second canal directly beneath it in 41.4% of cases. So access cavity should extend into the cingulum
- Outline may be triangluar or oval depending on prominence of mesial and distal pulp horns |
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Mandibular Canine
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Similar to maxillary canine but occasionally has 2 roots and 2 canals located labial lingually
- Must eliminate lingual shoulder to access lingual wall of canal or second canal - Access cavity is oval or slot shaped |
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Maxillary 1st premolar
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May have three canals in MB, DB, and Palatal
- Buccal root may fenestrate - Access shape is oval or slot shaped, but if there is three canals, outline form becomes triangular |
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Maxillary second premolar
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Similar to maxillary first molar and may have two or three canals
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Mandibular 1st premolar
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Very difficult tooth to treat and has a high flare-up rate
- Sometimes has 3 roots and 3 canals, and lingual orientation directs files into the buccal root - Oval shaped, with access centered between the cusp tips |
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Mandibular second premolar
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Lingual pulp horn is usually larger
- More often oval shaped but can be triangular shaped if 3 cusps are present - Access cavity form varies in atleast 2 ways in its external anatomy - Because crown has a smaller lingual inclination, less extension up the buccal incline is required - Because lingual half of tooth is more fully developed, lingual extension is typically halfway up the lingual cusp incline |
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Pre-op films for tooth #3 and for Anteriors
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#3: One buccal PA, one distal angled PA
Anteriors: Buccal PA, Mesial PA |
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Five types of longitudinal tooth fractures
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Craze lines
Fractured cusp Cracked tooth Split tooth Vertical root fracture |
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Cracked tooth syndrome
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Acute pain on mastication of grainy tough foods, and sharp brief pain with cold
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Craze lines
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Most adult teeth have craze lines usually crossing marginal ridges and extending along buccal and lingual surfaces
- Long vertical craze lines commonly appear on anteriors. Since they only affect enamel, its only esthetic. Use transillumination. Entire tooth will light up with a craze line |
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Fractured cusp
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Defined as a complete or incomplete fracture initiated from crown of tooth and extending subgingivally
- Usually involves two aspects of a cusp by crossing marginal ridge and extending down a buccal or lingual groove - Treat with cuspal reinforced restoration like full crown or onlay |
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Cracked tooth
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Incomplete fracture initiated from the crown and extending subgingivally usually directed mesiodistally
- May be described as incomplete or greenstick fractures - If detected, use wedging to test for movement of segments to differentiate with fractured cusp or split tooth. No mobility with wedging indicates cracked tooth Pulpal and periapical diagnosis, not just crack detection determines the final treatment plan |
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Split tooth
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Complete fracture initiated from the crown and extending subgingivally usually directed mesiodistally through both marginal ridges
- Split teeth can never be saved in tact. If fracture is severe, tooth must be extracted. If fracture shears to a middle to cervical third of tooth, larger segment may be saved |
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Vertical root fracture
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True vertical root fracture is defined as a complete or incomplete fracture initiated from the root at any level usually directed buccolingually
- Almost always associated with endo treatment, and presents with minimal signs and symptoms till periapical pathosis occurs. - Only predictable treatment is removal of fractured root or extraction |
