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????