Clinic, diagnostics of acute
forms of pulpitis. Clinic,
diagnostic of chronic forms
of pulpitis and their
exacerbation. Differential
diagnostic of different forms
of pulpitis.
Introduction
Endodontics is the specialty of dentistry
that manages the prevention,
diagnosis, and treatment of the dental
pulp and the periradicular tissues that
surround the root of the tooth
Causes of Pulpitis
1. Physical irritation
Most generally brought on by extensive decay.
2. Trauma
Blow to a tooth or the jaw
3. Anachoresis
- retrograde infections
Signs and Symptoms
Pain when biting down
Pain when chewing
Sensitivity with hot or cold beverages
Facial swelling
Discolouration of the tooth
Endodontic Diagnosis
Subjective examination
Chief complaint
Character and duration of pain
Painful stimuli
Sensitivity to biting and pressure
Discolouration of tooth
Important questions?
What do you think the problem is?
Does it hurt to hot or cold?
Does it hurt when you’re chewing?
When does it start hurting?
How bad is the pain?
What type of pain is it?
How long does the pain last?
Does anything relieve it?
How long has it been hurting?
Objective examination
Extent of decay
Periodontal conditions surrounding the tooth in
question
Presence of an extensive restoration
Tooth mobility
Swelling or discoloration
Pulp exposure
Challenges in diagnosis of pulpitis
Referred pain & the lack of proprioceptors in
the pulp localizing the problem to the correct
tooth can often be a considerable diagnostic
challenge
Also of significance is the difficulty in relating the
clinical status of a tooth to histopathology of
the pulp in concern
Unfortunately, no reliable symptoms or tests
consistently correlate the two.
Diagnostic Tests
Percussion
Palpation
Thermal
Electrical
Radiographs
1. Percussion tests
Used to determine whether the inflammatory
process has extended into the periapical tissues
Completed by the dentist tapping on the incisal
or occlusal surface of the tooth in question with
the end of the mouth mirror handle held parallel
to the long axis of the tooth
2. Palpation tests
Used to determine whether the inflammatory
process has extended into the periapical tissues
The dentist applies firm pressure to the mucosa
above the apex of the root
3. Thermal sensitivity
Necrotic pulp will not respond to cold
or hot
1. Cold test
Ice, dry ice, or ethyl chloride used to
determine the response of a tooth to cold
2. Heat test
Piece of gutta-percha or instrument
handle heated and applied to the facial
surface of the tooth
Evaluation of thermal test results
4 distinct responses:
1. No response non-vital pulp or false
negative
2. Mild response normal
3. Strong but brief reversible
4. Strong but lingering irreversible
Causes of false positives/negative
1. Calcified canals
2. Immature apex – usually seen in young
patients
3. Trauma
4. Premedication of the patient – pulp
sedated
4. Electric pulp testing
Delivers a small electrical stimulus to the
pulp
Factors that may influence readings:
Teeth with extensive restorations
Teeth with more than one canal
Dying pulp can produce a variety of responses
Moisture on the tooth during testing
Batteries in the tester may be weak
Placement of a pulp tester.
5. Radiographs
1. Pre-operative radiograph
Invaluable diagnostic tool
Periapical radiolucency
Widening of PDL
Deep caries
Resorption
Pulp stones
Large restorations
Root fractures
Requirements of Endodontic Films
Show 4-5 mm beyond the apex of the
tooth and the surrounding bone or
pathologic condition.
Present an accurate image of the tooth
without elongation or fore-shortening.
Exhibit good contrast so all pertinent
structures are readily identifiable.
Quality radiograph in endodontics.
Diagnostic Conclusions
1. Normal pulp
2. Pulpitis
Normal pulp
There are no subjective symptoms or objective
signs. The pulp responds normally to sensory
stimuli, and a healthy layer of dentine
surrounds the pulp
Pulpitis
The pulp tissues have become inflamed
Can be either:
Acute
– inflammation of the periapical area
– usually quite painful
Chronic
Continuation of acute stage or
low grade infection
Acute Pulpitis
mainly occurs in children teeth and
adolescent
pain is more pronounced than in chronic
Symptoms and Signs of acute pulpitis
The pain not localized in the affected tooth is
constant and throbbing worse by reclining or
lying down
The tooth becomes painful
with hot or cold stimuli
The pain may be sharp and stabbing
Change of color is obvious in the affected tooth
swelling of the gum or face in the
area of the affected tooth
Forms of acute pulpitis
1. Form of purulent acute where the pulp is
totally inflammed
2. Form of gangrenous acute where the
pulp begins to die in a less painful manner
that can lead into the formation of an
abscess
Chronic Pulpitis
1. Reversible
2. Irreversible
Reversible pulpitis
The pulp is irritated, and the patient is
experiencing pain to thermal stimuli
Sharp shooting pain
Duration of the pain episode lasts for
seconds
The tooth pulp can be saved
Usually this condition is caused by
average caries
Irreversible pulpitis
The tooth will display symptoms of lingering
pain
pain occurs spontaneously or lingers
minutes after the stimulus is removed
patient may have difficulty locating the tooth
from which the pain originates
As infection develops and extends through
the apical foramen, the tooth becomes
exquisitely sensitive to pressure and
percussion
A periapical abscess elevates the tooth from
its socket and feels “high” when the patient
bites down
Periradicular abscess
An inflammatory reaction to pulpal infection that
can be chronic or have rapid onset with pain,
tenderness of the tooth to palpation and
percussion, pus formation, and swelling of the
tissues.
Periodontal abscess
An inflammatory reaction frequently
caused by bacteria entrapped in the
periodontal sulcus for a long time. A
patient will experience rapid onset, pain,
tenderness to palpation and percussion,
pus formation, and swelling.
Destruction of the
periodontium occurs
Periradicular cyst
A cyst that develops at or near the root
of a necrotic pulp. These types of cysts
develop as an inflammatory response to
pulpal infection and necrosis of the pulp
Pulp fibrosis
The decrease of living cells within
the pulp causing fibrous tissue to
take over the pulpal canal
Necrotic tooth
Also referred to as non-vital. Used to
describe a pulp that does not respond to
sensory stimulus
Tooth is usually discoloured
Plan of Treatment
Depends widely on the diagnosis
Simple plan of treatment
Visit 1:
Medical history
History of the tooth
Access cavity
Place rubberdam
Extirpation + irrigation with sodium hypochlorite
Placed intra-canal medication (calcium
hydroxide)
Place cotton pellet
Placed temporary restoration (IRM/Kalzinol)
Visit 2:
Working length determination
Debridement using the hybrid technique
Irrigation
Placed intra-canal medication (calcium
hydroxide)
Place cotton pellet
Placed temporary restoration (IRM/Kalzinol)
Visit 3:
Obturation of the canal using lateral
condensation
Placed temporary/permanent
restoration (IRM/Kalzinol)
Referral
To appropriate discipline
Remember
Access cavity shapes:
1. Anterior – inverted triangle
2. Premolars – round
3. Molars – rhomboid
Always use rubberdam
Never to use Cavit as a temporary restoration
Always place an intra-canal
medication….calcium hydroxide!!!
Always use RC Prep or Glyde when filing
Contraindications for RCT
Caries extending beyond bone level
Rubberdam cannot be placed
Crown of tooth cannot be restored in restorative dentistry
nor prosthodontics
Patient is physically/mentally handicapped and therefore
cannot follow OH instructions
Putrid OH
Unmotivated patient
Severe root resorption
Vertical root fractures
Cost factor
Inter & cross-departmental diagnosis
Mobile teeth
Teeth associated with severe periodontal
problems
Confusion between TMJ dysfunctional
symptoms and RCT pain
Many decayed teeth
Sclerosed canal due to trauma
Uncertainty of prognosis related to abscess,
severe caries, facial swelling, cellulites, and
medical condition of patient
Referral to post-grad clinics
Extensive internal or external root
resorption
Severely curved, narrow, tortuous canals
Full-mouth rehabilitation required
Multiple exposures due to
attrition/abrasion
Problems with occlusion causing the need
for RCT
PULPAL DISEASE
Classified as:
Reversible pulpitis
Irreversible pulpitis
Necrotic pulp
Pulpal Disease
Reversible
Pulpitis
Reversible Pulpitis
Condition should return to normal with
removal of the cause.
Common causes:
Caries, recent restorative procedures, faulty
restorations, trauma, exposed dentinal tubules,
periodontal scaling.
Pulpal recovery will occur if reparative
cells in the pulp are adequate.
Symptoms of Reversible Pulpitis
Thermal:
Hypersensitive with mild pain of <30 seconds, but
similar to control tooth
Sweets:
Sensitive (if caries, crack, or exposed dentin) with mild
pain of <30 seconds (similar to control tooth)
Biting Pressure:
None (unless tooth is cracked)
Clinical Findings in
Reversible Pulpitis
Visual Check for decay, fracture lines, swelling, sinus tracts,
orientation of tooth, and hyperocclusion
Palpation Not sensitive
Percussion Not sensitive
Mobility None (unless periodontal condition exists)
Perio probing WNL (unless concomitant periodontal disease exists)
Thermal Hypersensitive to heat or cold
EPT Responds
Translumination Not used unless a fracture is suspected
Selective Not necessary
anesthesia
Test cavity Not necessary, tooth is vital
Radiographic Periapical x-ray shows normal periapex
Diagnosis
Reversible Pulpitis
If there is a discrepancy between the
patient’s chief complaint, symptoms, and
clinical examination – obtain more
information or data interpretation.
Remember: both a preoperative pulpal
and periapical diagnosis are made before
treatment is initiated (if reversible pulpitis is only
condition, the periapical area should be normal).
If the tooth is percussion sensitive –
consider bruxism or hyperocclusion.
Pulpal Disease
Irreversible
Pulpitis
Irreversible Pulpitis
Pulpal inflamation and degeneration not
expected to improve.
A physiologically older pulp has less ability to
recover due to decrease in vascularity and
reparative cells.
As inflammation spreads apically, cellular
organization begins to break down.
Localized pressure slows venous return,
resulting in buildup of toxins and lower pH that
causes widespread cellular destruction.
Symptoms of Irreversible Pulpitis
Thermal:
Hypersensitive with moderate to severe
prolonged pain (>30 seconds) as compared to
the control
Sweets:
Moderately to severely sensitive (if caries,
crack, or exposed dentin)
Biting Pressure:
Usually sensitive in later stages (periapical
symptom)
Moderate to severe spontaneous pain
Clinical Findings in
Irreversible Pulpitis
Visual Check for decay, fracture lines, swelling, sinus tracts,
orientation of tooth, and hyperocclusion
Palpation No response initially; may be sensitive in later stages
Percussion No response initially; may be sensitive in later stages
Mobility None (unless periodontal condition exists)
Perio Probing WNL ( unless concomitant periodontal disease exists)
Thermal Hypersensitive to hot and cold with prolonged response
EPT Responds
Translumination Not used unless fracture is suspected
Selective May help identify offending tooth
Anesthesia
Test cavity Not necessary, tooth is vital
Radiographic Normal or thickened periodontal ligament
Diagnosis
Irreversible Pulpitis
Hypersensitive to hot or cold that is
prolonged.
A history of spontaneous pain.
Vital or partially vital pulp.
Pulpal Disease
Necrotic
Pulp
Necrotic Pulp
Results from continued degeneration of an
acutely inflamed pulp.
Involves a progressed breakdown of cellular
organization and no reparative potential.
Commonly have apical radiolucent lesion.
(always conduct proper pulp testing to rule out a
non-pulpal origin).
With multi-rooted teeth, one root may contain
partially vital pulp, whereas other roots may be
nonvital (necrotic).
Maxillary first molar with large amalgam restoration and
periapical radiolucencies around all three roots. The tooth
was unresponsive to electrical and thermal testing.
Periapical radiolucency of canine and premolar. The
canine was responsive to pulp and thermal testing.
Symptoms of Necrotic Pulp
Thermal:
No response
Sweets:
No response
Biting Pressure:
Usually moderate to severe pain (not symptom of
necrotic pulp, but rather periapical inflammation)
Moderate to severe spontaneous pain
(usually dull and throbbing; associated with periapical area)
Clinical Findings in
Necrotic Pulp
Visual Check for decay, fracture lines, swelling, sinus tracts,
orientation of tooth, and hyperocclusion
Palpation Sensitive
Percussion Mild to severe pain (depends on periapex inflammation)
Mobility None to moderate (depends on bone loss)
Perio Probing WNL ( unless concomitant periodontal disease exists)
Thermal No response
EPT No response
Translumination Not used unless fracture is suspected
Selective May help identify offending tooth
anesthesia
Test cavity May be used if vitality is suspected
Radiographic Periapical radiograph may show normal or thickened
periodontal ligament, or radiolucent lesions
Chronic pulpitis
chronic pulpitis with a closed pulp
chamber
chronic ulcered pulpitis
hyperplastic pulpitis
residual pulpitis
retrograde pulpitis
chronic pulpitis with a closed pulp
chamber
---deep caries/recurrent caries
extensive restorations(near the chamber)
---detection: bluntness/inaction
---percussion: (+)
---pulp test: no-reaction/slow-reaction
---radiogralph:“thicken” periodontal
membrane
chronic ulcered pulpitis
---typical complain painful when compressed
by food packed into the cavity
---pulp chamber opened and ulcered pulp
---detection: pain and bleeding
---percussion: (+)
hyperplastic pulpitis
---typical complain, bleeding when chewing
---pulp polyp
---tartar in the same side
---in young people
---distinguish from the other polyp
residual pulpitis
---treated tooth (uncomfortable treatment)
missing canal, residual pulp
---percussion: (+)
---pulp test(strong): slow-reaction
---radiogralph:“thicken” periodontal
membrane
---final decision: painful when canal detection
retrograde pulpitis
---pulpitis and periodontitis
---deep periodontal pocket
---percussion: (+~++)
---pulp test: difference
---radiogralph：radiolucency around
the root and furcation
Electric pulp testing
‡Delivers a high frequency current to
desired tooth.
‡To determine the presence or absence of
sensory nerves (pulp vitality).
Stimulated nerves are of the myelinated A-
delta fiber group.
How to perform EPT ?
Clean, dry & isolate tooth.
‡
Scrub facial surface with a dry cotton roll and
isolate with the same roll.
‡Make sure tooth is dry by air syringe.
‡Attach the clip of the device to patients lip or let him
hold it( closes the electrical circuit).
‡Apply toothpaste or conducting medium to the
electrode & touch tooth.
‡A control test must be performed on a non affected
tooth to make sure patient has a normal threshold
of stimulation
Differential diagnosis
Acute pulpitis
(pain is spontaneous and more intense)
Deep situated carious lesion
( pulp is stimulated in the same way but
stimulus subsides immediately)
Differential diagnosis
Pulp necrosis
( same symptoms but pain is only
triggered on hot irritant, also a
continuity between cavity and pulp
exists )
Prognosis of untreated teeth:
Inflamed
‡ tissue will change into granulation
tissue due to persistent irritation.
‡ Later on fibrous tissue will form.
‡ From this point several pathologies may arise
-necrosis
-internal resorption
-calcification of pulp chamber
-pulpal stones
It is important to keep in mind that a chronic form
may turn to the acute form in cases of
decreased immunity.
Questions????
