1. Toothaches of Dental Origin
Diagnosis
and
Management
Material used by permission from B.C. Decker Publishing Co.

2. Initial Guidelines
Before treating, determine a separate pulpal and periapical diagnosis based on history and responses to clinical tests.
Focus first on pulpal signs and symptoms, and then periapical signs and symptoms.
Pulpal inflammation can eventually result in periapical inflammation.
A tooth with a large periapical radiolucency must have a necrotic pulp, if the lesion is of endodontic origin.

3. Guidelines, con’t.
Post-op pain management for patients requiring a pulpotomy or pulpectomy:
Pre-emptive analgesia: prior to the procedure, give the patient ibuprofen 600mg plus acetaminophen 1000mg, orally.
Contraindications: hypersensitivity to NSAIDs or ASA, pregnancy, asthma, CHF, hypertension, decreased renal or hepatic function, GI bleeding or ulcers, or those on anticoagulant drugs.
Injection of 0.5% marcaine following the procedure.

4. PULPAL DISEASE Classified as: Reversible pulpitis
Irreversible pulpitis
Necrotic pulp

5. Pulpal Disease
Reversible
Pulpitis

6. 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.

7. 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)

8. Clinical Findings in Reversible Pulpitis
Visual
Check for decay, fracture lines, swelling, sinus tracts, orientation of tooth, and hyperocclusion
Palpation
Not sensitive
Percussion
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 anesthesia
Not necessary
Test cavity
Not necessary, tooth is vital
Radiographic
Periapical x-ray shows normal periapex

9. 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.

10. Treatment of Reversible Pulpitis
Remove irritant if present (caries; fracture; exposed dentinal tubules).
If no pulp exposure: CaOH, restore, monitor
If pulp exposure:
Carious: initiate RCT
Mechanical: >1 mm: initiate RCT
<1 mm crown planned: initiate RCT
<1 mm: direct cap or RCT
If recent operative or trauma – postpone additional treatment and monitor.

11. Pulpal Disease
Irreversible
Pulpitis

12. 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.

13. 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

14. 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
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
Anesthesia
May help identify offending tooth
Test cavity
Not necessary, tooth is vital
Radiographic
Normal or thickened periodontal ligament

15. Diagnosis Irreversible Pulpitis
Hypersensitive to hot or cold that is prolonged.
A history of spontaneous pain.
Vital or partially vital pulp.

16. Treatment of Irreversible Pulpitis
Minimum immediate treatment (if not extraction)
Pulpotomy:
Remove all decay (essential)
Large canals: passively broach 75% of tooth length
Small canals: spoon excavate orifice while removing pulpal tissue from chamber.
Copious irrigation with sodium hypochlorite (1%).
Dry chamber with cotton pledget
Place Ca(OH)² into large and over small canals
Place dry cotton pellet in chamber, cover with cavit, temporarily restore with Ketac-fill; completely relieve occlusion if have acute apical peridontitis

17. Treatment of Irreversible Pulpitis
Ideal immediate treatment
Pulpectomy (complete removal of pulpal tissue)
Determine the ideal working length (WL)
Fully instrument canals with master apical file
At least # 25 file for small canals (and anterior teeth)
# file for larger canals
Alternate working files with #8 or 10 patency file
Copious irrigation with sodium hypochlorite (1%)
Dry chamber with cotton pledget
Place dry cotton pellet over canals, cover with cavit, temporarily restore with Ketac-fill; completely relieve occlusion if have acute periapical peridontitis.

18. Ideal Access Preparations

19. Irreversible Pulpitis (more treatment considerations)
Any residual decay can result in an inadequate seal, contamination of canal space, and inter-appointment flare-ups.
Inflammation can be judged by the amount of hemorrhage from the remaining pulp stump. If bleeding continues, re-broach or file for residual pulpal tags with copious irrigation.
To decrease risk of instrument separation within the canal space, do not engage the canal walls with broach.

20. Irreversible Pulpitis (additional considerations)
Do not leave teeth open between appointments – causes contamination of the canals and difficulty closing them later.
Incomplete tooth fractures involving the pulp will show symptoms of irreversible pulpitis. Periodontal probing of associated pocket will indicate depth of fracture. If depth of pocket (fracture) extends below the attachment level, the prognosis is guarded to poor.

21. Pulpal Disease
Necrotic
Pulp

22. 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).

23. Maxillary first molar with large amalgam restoration and periapical radiolucencies around all three roots. The tooth was unresponsive to electrical and thermal testing.

24. Periapical radiolucency of canine and premolar
Periapical radiolucency of canine and premolar. The canine was responsive to pulp and thermal testing.

25. Symptoms of Necrotic Pulp
Thermal:
No response
Sweets:
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)

26. 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
Translumination
Not used unless fracture is suspected
Selective anesthesia
May help identify offending tooth
Test cavity
May be used if vitality is suspected
Radiographic
Periapical radiograph may show normal or thickened periodontal ligament, or radiolucent lesions

27. Diagnosis of Necrotic Pulp
Distinguishing features:
No response to cold.
No response to EPT.
Caveats
Decreased sensitivity to cold/ept may be from of insulating effects of additional dentin.
Fluid in canal space conducting electrical current can give false-positive.
Periapical radiolucency is strong but not conclusive evidence that pulp is necrotic.

28. Treatment of Necrotic Pulp
Minimum immediate treatment (if not extraction)
Partial instrumentation of canals:
Remove all decay, evaluate restorability
Determine working length of all canals
Large canals: up to #40 file, 4mm short of WL
Small canals: up to #25 file, 4mm short of WL
Alternate working file with #8 or 10 patency file
Copious irrigation with sodium hypochlorite (1%)
Dry chamber with cotton pledget
Place Ca(OH)² into all canals
Place dry cotton pellet in chamber, cover with cavit, temporarily restore with Ketac-fill; completely relieve occlusion if have acute apical periodontitis.

29. Treatment of Necrotic Pulp
Ideal immediate treatment
Complete instrumentation of canals:
Determine the ideal working length
Fully instrument canals with master apical file
At least # 25 file for small canals (and anterior teeth)
# file for larger canals
Alternate with #8 or 10 patency file
Copious irrigation with sodium hypochlorite (1%)
Place dry cotton pellet over canals, cover with cavit, temporarily restore with Ketac-fill; completely relieve occlusion if have acute apical periodontitis.

30. Necrotic Pulp (additional considerations)
Antibiotic coverage
Usually not required unless patient has progressive swelling or fever.
Pain Management
Always determine allergy, contraindication, and interaction with present medications
Clock regulate NSAID (ibuprofen) for 3 days
Narcotic for approximately 3 days, if needed
Occlusal Reduction
Reduction in all cases with acute apical periodontitis (remember that length measurements may change)

31. PERIAPICAL DISEASE Classified as: Acute Apical Periodonitis
Acute Apical Abscess
Chronic Apical Periodontitis
(Suppurative Apical Periodontitis with sinus tract)
Condensing Osteitis

32. Treatment of Periapical Disease
Pulpal status
always dictates treatment
of periapical disease

33. Periapical Disease
Acute Apical
Periodontitis

34. Acute Apical Periodontitis
Mild to severe inflammation that surrounds or is closely associated with the apex of a tooth.
Results from:
Irreversible inflammation or necrotic pulp.
Trauma or bruxism of normal or reversibly inflamed pulpitic conditions.
Consider vertical fractures, periodontal abscess, and non-odontogenic pain.

35. Clinical Findings in Acute Apical Periodontitis
Visual
Check for decay, fracture lines, swelling, sinus tracts, orientation of tooth, and hyperocclusion
Palpation
Sensitive (usually on buccal surface)
Percussion
Moderate to severe (initially use index finger to reduce patient discomfort)
Mobility
Slight to no mobility (if moderate mobility exists, check for possible periodontal condition before continuing)

36. Acute Apical Periodontitis, con’t.
Perio Probing
WNL (unless concomitant periodontal disease or vertical fracture exists)
Thermal (pulpal symptom)
Response (not prolonged) – consider traumatic occlussion
If response prolonged – consider irreversible pulpitis
No response – consider necrotic pulp
EPT (pulpal test)
Response – pulp is vital (reversible or irreversible)
No response – pulp is necrotic

37. Acute Apical Periodontitis, con’t.
Translumination
Not used unless fractured is suspected
Selective Anesthesia
Not necessary, offending tooth easily located
Test cavity
Not necessary
Radiographic
Periapical image does not show a radiolucent lesion; some thickening of the periodontal ligament is common

38. Immediate Treatment of Acute Periapical Periodontitis
If from irreversible pulpitis:
Pulpotomy or extraction.
If from necrotic pulp:
Root canal therapy initiated or extraction.
If from hyperocclusion:
When the pulp is normal or reversibly inflamed, adjusting the occlusion provides immediate relief. Always consider cracked tooth, irreversible pulpitis, or necrotic pulp if discomfort persists.
If from bruxism:
A biteguard may be indicated.

39. Periapical Disease
Acute Apical
Abscess

40. Acute Apical Abscess
Acute inflammation of the periapical tissue characterized by localized accumulation of pus at the apex of a tooth.
A painful condition that results from an advanced necrotic pulp.
Patients usually relate previous painful episode from irreversible or necrotic pulp.
Swelling, tooth mobility, and fever are seen in advanced cases.

41. Symptoms of Acute Apical Abscess
Spontaneous dull, throbbing, persistent pain; exacerbated by lying down.
Percussion:
Extremely sensitive
Mobility:
Horizontal / vertical; often in hyperocclusion
Palpation:
Sensitive; vestibular or facial swelling likely
Thermal:
No response

42. Clinical Findings of Acute Apical Abscess
Visual:
Check for decay, fracture lines, swelling, sinus tracts, orientation of tooth, hyperocclusion
Palpation:
sensitive; intraoral or extraoral swelling present
Percussion:
Moderate to severe (initially use index finger)
Mobility:
Slight to none; may be compressible
Perio probing:
WNL (unless have perio disease or vertical fracture)

43. Acute Apical Abscess, con’t.
Thermal:
No response (pulp is necrotic)
EPT:
No response (false-positive from fluid in canal)
Translumination:
Not used unless fractured is suspected
Selective Anesthesia:
Not necessary, offending tooth easily located
Test cavity:
Not necessary unless vitality is suspected

44. Acute Apical Abscess, con’t.
Radiographic:
Thickening of the periodontal ligament is common; may not show a frank lesion
If tests indicate pulp vitality: (red flag!)
Review diagnostic information (repeat diagnostic tests)
Rule out lateral periodontal abscess
Review medical history for previous malignant lesions or other conditions (hyperparathyroidism) that may explain contradictory information
Do not begin treatment until this discrepancy has been resolved

45. Treatment of Acute Apical Abscess (necrotic pulp)
Minimum immediate treatment (if not extraction)
Partial instrumentation of canals:
Remove all decay, evaluate restorability
Determine working length of all canals
Achieve apical patency all canals with #10 file, look for drainage and allow to continue until it stops
Large canals: up to #40 file, 4mm short of WL
Smaller canals: up to #25 file, 4mm short of WL
Alternate with #8 or 10 patency file
Copious irrigation with sodium hypochlorite (1%)
Dry chamber with cotton pledget
continued on next slide

46. Treatment of Acute Apical Abscess, con’t.
Place Ca(OH)² into all canals
Place dry cotton pellet in chamber, cover with cavit, temporarily restore with Ketac-fill, and completely relieve tooth from occlusion.
Incision and drainage may be required
Prescribe antibiotics and analgesics
Continued pain and swelling are common postoperative problems – so prepare the patient for several days of discomfort.

47. Periapical Disease
Chronic Apical
Periodontitis

48. Chronic Apical Periodontitis
Results from prolonged inflammation that has eroded the cortical plate making a periapical lesion visible on the radiograph.
Caused by a necrotic pulp, the lesion contains granulation tissue consisting of fibroblasts and collagen (with macrophages and lymphocytes).
Must rule out central giant cell granuloma, traumatic bone cyst, and cemental dysplasia.
Usually asymptomatic, but in acute phase may cause a dull, throbbing pain.

49. Chronic apical periodontitis
Chronic apical periodontitis. Extensive tissue destruction in the periapical region of a mandibular first molar occurred as a result of pulpal necrosis. Lack of symptoms together with presence of a radiographic lesion is diagnostic.

50. Chronic Apical Periodontitis, con’t.
Most common pitfall is assuming that the presence of a periapical lesion automatically indicates a necrotic pulp.
If tests indicate pulp vitality: (red flag!)
Review diagnostic information (repeat diagnostic tests)
Rule out lateral periodontal abscess, central giant cell granuloma, traumatic bone cyst, and cemental dysplasia.
Review medical history for previous malignant lesions or other conditions (hyperparathyroidism) that may explain contradictory information
Do not begin treatment until this discrepancy has been resolved

51. Periapical radiolucencies associated with mandibular incisors
Periapical radiolucencies associated with mandibular incisors. These teeth were vital, and a diagnosis of cemental dysplasia was made.

52. Treatment of Chronic Apical Periodontitis (necrotic pulp)
If asymptomatic, no immediate treatment needed; schedule for root canal therapy
If in acute suppurative phase, immediate treatment same as with acute apical abscess, i.e.,
Partial instrumentation of canals:
Remove all decay, evaluate restorability
Determine working lengths of all canals
Achieve apical patency all canals with #10 file, look for drainage and allow to continue until it stops
Large canals: up to #35 file, 4mm short of WL
Smaller canals: up to #25 file, 4mm short of WL
Alternate with #8 or 10 patency file

53. Treatment of Chronic Apical Periodontitis, con’t.
Copious irrigation with sodium hypochlorite (1%)
Dry chamber with cotton pledget
Place Ca(OH)² into all canals
Place dry cotton pellet in chamber, cover with cavit, temporarily restore with Ketac-fill, and completely relieve tooth from occlusion.
Incision and drainage may be required
Prescribe antibiotics and analgesics
Continued pain and swelling are common postoperative problems – so prepare the patient for several days of discomfort.

54. Periapical Disease
Condensing
Osteitis

55. Condensing Osteitis
Increased trabecular bone in response to persistent irritant diffusing from the root canal into the periradicular tissue.
May be either asymptomatic (pulpal necrosis) or associated with pain (pulpitis).
Therefore, may or may not respond to diagnostic tests, i.e., thermal, electric, palpation, percussion.
Root canal treatment, when indicated, may result in complete resolution.

56. Inflammation followed by necrosis in the pulp of the first molar has resulted in the diffuse radiopacity of the periradicular tissue.