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The Differential Diagnosis of Toothache inflammation by benbenzhou

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The Differential Diagnosis of Toothache inflammation

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									The Differential Diagnosis of Toothache                                   12.03.07
ICS II Fall 2007

Black – Chris Nelson’s Notes from Dr. Gluskin’s morning lecture
Red – Reena & Valerie’s Notes from Dr. Peters’ afternoon lecture

Pulpal Environment
   - Low compliance (unyielding walls)
          o Only so much the pulp can swell before problems happen
          o Compliance = soft thing in a hard shell; idea being that this is a major
              driver in pulpal disease
                   Any other tissues w/same type of tissue as tooth pulp?
                           Certain body parts we won’t discuss
          o Typical sign of inflammation?
                   How do you picture a pulp dying?
                   Bacteria get into the pulp –
                           Start out w/small abscess that can enlarge inside the pulp so
                             that the tissue becomes necrotic
                           More and more tissue becomes necrotic
                           Can stop it by sealing off bacteria!
   - No collateral circulation
          o Well, really, the collateral circulation is less… there is a bit via lateral
                   Formed by breaks in the epithelial rests – hertwig’s (sp?) sheathe
   - Localized tissue pressure

Could you tell me about your problem?
   - Inception
          o When it started to bother you
          o If chewing gum was inception:
                   Periodontal possibly
                   Fluid movement possibly – changing the concentration of the
                     dentinal tubules – in order to dilute the sugar – so an osmotic
                     gradient to sugar
                          Words of wisdom: A toothache after any provocation is an
                             indication of irreversible pulpitis!
   - provoking factors
          o what brings you in today? How are you doing?
          o Be simplistic
                   Where does it bother you?
                   What bothers you? (don’t put ideas into their head.. let them
                     explain to you what they sense/feel)
          o things that can produce the complaint that the pt is coming in for
                   if the pt comes in because they can’t stand heat, apply heat!
          o Percussion
          o Sugar

                                      Page 1 of 10
           o Hot
           o Cold
           o Etc…
   -   Location
           o Important, but not the only factor necessary because can be misleading
   -   Intensity
           o Scale of 1 to 10 = Visual analog scale
           o Descriptors of the most intense pain:
                   Throbbing
                   Constant, never goes away
                   Affects my daily routine
                          “Can’t do Jack anymore” – Dr. Gluskin
                   Trismus
   -   Frequency
           o What is causing it?
                   Chewing nuts
                   Granola
   -   Duration
           o If lingering, irreversible pulpitis
   -   Quality

DIAGNOSTIC TOOLS (most invasive is radiographic, least invasive is patient hx then
percussion then radiographs)
    - Patient history
           o Some treatment that was deep and in close proximity to the pulp
           o Trauma or ice chewers, etc…
           o Orthodontic treatment
           o Times a tooth has been filled – pulp inflammation is cumulative!!!!
                   This is a critical point that you should not forget.
                   Every time you prepare a tooth, you may have introduced an
                      inflammatory event that can cumulate with future or past events
                      such as filings
                   Every tooth you’re going to crown should be pulp tested
    - Percussion
           o Not “could” but “does” indicate inflammation of the pdl space
           o Indicates bone inflammation
           o How go about it?
                   Back end of mirror with some force but not much
                   What is the sequence of pt came in and said LL sore and no
                      radiographs (don’t take them so soon! Use your ears and eyes)
                           Luma: If touch area and it makes pt. feel better (no
                             swelling) how do you dx w/o radiographs
                           Start off w/contralateral or other tooth and pulp test
                                  o Two adjacent teeth, the one in question and two
                                      contralateral teeth
    - Palpation

                                     Page 2 of 10
       o of sensitive root
       o check if swelling, texture and feeling of swelling noted
       o look for
                indurated swelling
                fluctuant swelling
-   Radiographs
       o Most invasive : so gather as much info as you can before you take xrays
       o Pano a good option for some situations
       o Most important radiograph
                Bite wing!
-   Tests
       o If have crown on tooth you have to leave it on longer but “might” damage
           pulp by leaving the “test” item on longer (cold, hot, etc)
       o Burr speed – high speed with water cooling is very sufficient to cool pulp
           provide the water cooling is correct (some handpieces have 3 ports and
           some have 1 port for cooling)
       o At what temp does protein get denatured? 42 degrees Celcius
-   Cold test
       o Infrequently causes pulpal craze lines when CO2
       o What is unique about cold test?
       o Endo Ice – has CFCs (chlorofluorocarbons bad for the ozone layer)
       o Teeth are easier to test with a cold test rather than a hot test
       o Best is CO2 but we can’t get it to function properly
       o Exam question #12: reproduce the symptoms when have many carious
           teeth in a quadrant
       o Where do you apply the cold test? - it doesn’t matter much but Dr. Peters
           recommends buccal of teeth (even though the article states incisals of
           anteriors and lower molar MB cusp tip – “these articles aren’t always peer
           reviewed so be wary)
       o How can u classify a test as good or bad? – how good it is at finding out
           what the problem is.
       o Others:
                Hot test: when do you do a hot test? - if symptoms are induced by
                   heat.. (and need to duplicate the symptoms)
                        Hot gutta percha
                        Hot water with rubber dam around the tooth
                        Some heating instruments w/tips for pulp testing
                        Its not very commonly used – only when have particular
                            heat sensitivity.. not done every time but cold IS done
                            every time
                EPT: often last resort (do it if you can at UOP though) – where is it
                   applied to the tooth? To the incisal edge because the conduction of
                   the electric current varies. Good conduction of MB cusp tip in
                   upper molars into the pulp horns.
                        Does this damage the pulp? No

                                   Page 3 of 10
                          Electrodes – one on patients hand to connect electrode
                           (complete circuit).
                        The # goes up to 80
                        What does EPT tell you? – if tooth is vital or nonvital
                 Fiberoptics
                        Cracked/fractured tooth
                        Where do you do it?
                        Most often have fractures on posterior teeth – usually have
                           vertical fracture lines
                        Anterior usually have horizontal fracture lines
                        Where does fracture line appear for premolar? Generally
                               o BL or MD? – answer is BL - this is not where
                                   dentin is thininest (MD)… theory is that root canacl
                                   shape has a sharp angle that causes fracture line in
                                   BL direction
        o Evaluates vitality
        o Not always accurate
        o Response from a pt …does that mean the pulp is vital?
                 Could be a false positive
                 Don’t believe a single pulp test (any pulp test) ever, ever. Ever,
                        A pulp test really only tells you:
                               o The nerve tissue is able to conduct a response to the
                                   brain… that’s it. Period.
                               o Does not tell you whether it is vital or not.
-   Biting Pressure
        o PDL test
-   Periodontal Probe
-   Fiberoptics
        o Transillumination shows cracks
        o Carious lesions
        o Color changes
-   Palpation
-   Percussion
-   Mobility
        o A tooth with an acute endo infection will be mobile, especially in kids
        o Todays Quiz Q: class two to three mobile molar w/RL on M and D roots
           into furca
                 Had good Px!
                 Do an endo tx and has a favorable px
                 Has nothing to do w/perio
                 Wheres mobility coming from? Inflamm response
                 There is no bone loss.. PDL tissue is soft and expanded
                 Perio removes cementum but doesn’t allow reconstitution of

                                   Page 4 of 10
                    Can get healing w/endo
   -   Radiographs
           o N E V E R will show you irreversible pulpitis
                    Because the pulp is radiolucent
   -   Thermal tests
   -   Periodontal examination
   -   Test cavity
           o Prior to any restoration it is important to know vitality of that tooth, ESP
              an expensive restoration (like crowns). In Europe have to pulp test
              EVERY tooth undergoing any restorative (even fillings)… pulp test
              doesn’t cost a thing… gives you a great advantage as a clinician
           o Last resort
           o There is a necrotic tooth, and you need to know which one is necrotic
                    A tooth with a history, multiple restorations, etc…
           o Test the quickest route to dentin
   -   Anesthesia test
           o To rule out upper v lower, etc

Diagnostic Procedures
   - dental history
   - chief complaint
   - radiographs
   - thermal pulp tests
   - electronic pulp test
   - palpation
   - percussion

If patient can’t tell where it is coming from, what could the problem be?
    - Extreme pain due to acute irreversible pulpitis
            o Caused by: inflammation that is confined to the tooth! Only comes from a
                pulpitis where the inflammation is completely confined inside the tooth!
                      NOTE: as a class, we could not answer this question… so
                        memorize the answer.

Clinical photo 1
    - dark number nine
           o calcific metamorphosis = trauma causes calcification
           o radiolucency possibilities
                  carious area
                  burnout
                  internal/external resorption – take xray from many angles so RL
                     projects on top of root canal at every angle
           o trauma
           o ortho mvt
           o developmental
           o etc

                                      Page 5 of 10
   -   radiograph
           o looks mineralized?
           o Maybe external resorption?
                   If internal resorption, it will stay with the pulp chamber
                   If external resorption, it will move

   - under the chin big zit-like red spot (pre-eruption)
        o This case: Sinus tract connects some kind of area that isn’t preformed
            (inside of oral cavity to outside world)
                 Sinus tract does not have to be open at the end
                 Can be active or inactive
                 Parulis vs. sinus tract – parulis doesn’t have drainage
        o Fistula connects two hollow organs
        o Sinus tract does not equal fistula – different terms
        o Why would sinus tract go to oral cavity vs. outside world?
                 Path of least resistance rarely goes out to face (outside world)
                    because …..
                 Main component of path of least resistance is the position of the
                    apex – many factors
                         Length of tooth
        o bacterial infection of the jaw could be:
                 Staph
                 Actinomycies
        o Why does an infection drain extra orally as opposed to draining in the
            mouth? (3 answers)
                 Length of the root
                 Attachment of the muscles
                         If muscles are below the root apex, drains in mouth
                         If muscles are above the root apex, drains into the tissue
                 Direction of apical 1/3rd

   - eye swelling
        o right side of face
        o what is the origin of that swelling?
        o all uppers drain into the:
                 submandibular space

   - premolar – capacity of pulp ot survive additional restoration… what is chance of
       survinging? Already have large MODs with L cusps broken off. Bacteria can
       ingress into the pulp.. this is very likely. How can they get in if pulp is closed and
       no caries? How permeable is dentin? It is thin! 0.5mm is not very thick.
   - fractured cusps after MOD alloy
           o pulps are inflamed (for sure… not debatable)

                                        Page 6 of 10
           o unlikely the tooth will survive an FVC crown

Interpreting the language of pain
    - acute v chronic – subjective coloring can help
    - acute: PAIN, reversible pulpitis
    - chronic: NO PAIN, irreversible pulpitis  pulpal necrosis (total)

A-delta fibers
- located in pulp dentin interface
- myelinated (1um is myelinated… less than 1um is unmyelinated… 1m/sec
    conduction velocity with myelin)
- Large diameter
- What is the sensory modality (pain, temp, vibration, etc)??? (FAST PAIN)
    o (vs. C fibers- pain also the sensory modality)
    o Beta fibers: some research suggests these pick up elastic deformation of tooth
    o Fluid dynamics allow feeling
    o Odontoblastic processes – do not have somatic contact to nerve fibers
    o Hydrodynamic theory is important as is the nerve fiber from cells
- Nerve Fibers
    o Cell bodies in trigeminal ganglia
    o Pseudounipolar cells
    o Activated during temperature regulation
    o Respond when the inflammatory response sensitizes these fibers
    o Heat now elicits a response
    o Unmyelinated, small, located more centrally in the pulp
    o Give dull pain
- Both are polymodal receptors
- Only tell that there is pain in the periphery

Photo of bad looking RCT
   - Root canal with silver cone filling
           o Corrosion can occur
   - Retrograde completed with amalgam
   - Periapical radiolucency – when you take another radiograph, see much larger
       lesion that suggests problem with canine
           o Root canal done on canine and treatment is successful
   - Unlikely for bacteria to retroactively infect the already filled tooth
   - Chronic granuloma there is no bacteria
   - Very few bacteria that can live in the apex and not cause a problem – ie
   - Radiolucencies usually found around foramen
           o Where the irritants originate
           o Lateral radiolucencies
                    resorption
   - all of the radioopacity is metal in this particular incidence

                                      Page 7 of 10
   -   this tooth is a battery
            o so it is possible that there is a radiolucency because the electrical current is
                breaking down the tissue
   -   first thing you’ll do: take another radiograph!
            o Second radiograph shows that the adjacent tooth is actually the problem
            o Test vitality
                     Ice – doesn’t work
                     Lay a flap – doesn’t do anything – don’t do it
                     Percussion – no different feeling
                     Test cavity – YES

WARNING: X-rated endo
   X-tremely calcified
   X-cessively curved
   X-traordinarily abused

You do a test cavity to look for a necrotic tooth. If they feel it, patch the hole. The pulp
is vital. You want the non-vital pulp.

Why would one tooth mineralize completely and the other is fine? Trauma to only one
tooth, not the adjacent… not realistic.
Four responses to trauma:
    - resorption
    - necrosis
    - mineralization
            o by itself, this is not problematic, but it can be
    - healing

Pulps mineralize coronal to the apex… never apex to coronal!!!!

Teeth 8&9 radiograph: no pulp on #9 means hard tissue laid down
    must be low grade chronic rxn cuz entry of blood vessels compromised
    He doesn’t give a damn if he can see the canals… he needs to see if there is a big
       chamber. Chamber indicates a doable RCT.
    Calcified canal: calcific metamorphosis
    Can be due to trauma
    No symptoms – all you see from the outside of the tooth clinically is a yellowish
       less translucent tooth… pt. won’t know… tooth might test nonvital to cold cuz
       amount of vital pulp is quite diminished but not compressed to point of death.
    Is there any danger in leaving it? Its asymp… have chronic apical periodontitis
       then timeline is endless… if symptomatic address immediately

MB root durved. Palatal root has radiolucency. Looks like palatal root goes into sinus.
How far do u go into the root to establish patency? –

                                        Page 8 of 10
RL around #13 – no defined borders..
       Because there are multiple portals of exit – 2 lateral canals

SLIDE: Non-carious pathways in pulpal degeneration
       Trauma
            o Impact blood supply
            o Introduce bacteria into PDL and PA area
       Perio disease
            o When can it impact pulpal health?
                      If its severe enough to go into the apex
                      If pocket reaches the major apical foramen or major lateral
                         foramen (rare)… talked about at beginning of perio/endo
       Ortho movement
            o How would that impact pulpal health
                      Blood supply impacted
                      If movement too forceful
       Anatomical defects w/pulpal communication
            o Typical scenario for this is – dens in dente but this isn’t what he’s
                looking for, answer that he’s looking for is furcation canal which
                extends from pulpal space into the furcation (20% of molars have this)
                      In Pedo, whats the #1 sign for primary molar to be pulpally
                         involved – furcal RL
            o Note this scenario is not pulp stones – they are not diseased! Unless
                it’s a tooth that need RCT only then do you do endo
            o Lingual groove on a lateral incisor – can get a periodontal pocket
                that’s deep
       Surgical sequelae
            o How can it impact pulpal health?
            o Puting osteosynthesis titanium plate (surgical intervention that drills
                into apical space)
            o Osteotomy sever blood supply to maxillary teeth – teeth won’t
                respond normal to cold… prob have blood supply but nerves
                damaged.. difference btwn sensitivity (nerves) and vitality (blood!)

Lesions don’t just form around a root… there are typically lateral canals that feed a

Vesicles on the palate.
   - never a common presentation for endo, but might be herpes virus

Watch out for new teeth infections draining from old endo access sites.

Always do the sinus tract tracing.

Pain never crosses the midline of face with dental

                                       Page 9 of 10
Never cyclical with day or season w/ dental

Class V are closer to the root.

                                     Page 10 of 10

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