Oral Diagnosis 9

7/28/2019 Oral Diagnosis 9

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Assalamualaikum,we will continue from part 1

Chronic irreversible pulpitis.

As we said previously, there's no PA changes. The problem is still confined

within pulp but particularly it is chr pulpitis. Sometimes some specific changes

in the bone surrounding the root; sclerosing osteitis.

This tooth, did a crown. The pulp is chronically inflamed, but still vital. There

is sclerosis of pulp canal. It will be very difficult to do RCT in this case. This

sclerosis because of excessive reparative dentin. But here is sclerosing osteitis

Sometimes the bone of radiograpic changes increase bone density surrounding

the root of the tooth which have chronically inflamed pulp. Usually there'slocalized in such condition. Usually like diffuse sclerosis of the bone.

With chronic hyperplastic pulpitis, same like the case we saw previously.

Usually it affect children because they have big pulp chamber, very good blood

supply, apical foramen wide and flared, which will enhance blood supply. So


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this will help he pulp to maintain vital despite of excessive attack by the carious

lesion.

Sometimes it is very difficult to differentiate between chr. Hyperplastic pulpitis

and chr. Hyperplastic gingivitis. Here, it is very clear, because surrounded by

tooth structure. Sometimes it is larger in size that cover one or part of the tooth

structure.

You need to determine whether it is hyperplastic pulpitis or hyperplastic

gingivitis. Because sometimes if there's break in the tooth structure in such

condition, this might allow the deposition of food debris and then induce

gingivitis. And gingival might react like hyperplastic way and then become

hyperplastic gingivitis.

To differentiate between the two condition, by the probe, just try to remove or

determine the border of this growth, whether it is gingival in origin or from the

pulp, to know whether it is hyperplastic gingivitis or pulpitis.


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RG-Lamina dura is not fully formed but not because of there's acute apical

periodontitis. Roots are not fully formed. It needs time for fully formed then thelamina surrounding the root.

Another case of hyperplastic pulpitis.

This is inflamed pulp. There's excessive inflammatory cells and has epithelial

lining, like a growth. This epithelium lining in origin is not very well but it is

may because of the shedding of the epithelial cells from the oral cavity,

reaching the pulpal tissue and be like a proliferation and they form layer over

the pulpal tissue.


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Necrotic pulp

Clinical sign-discolored of tooth, carious tooth, maybe tooth crown or maybe

normal tooth with history of trauma. No pain is the most important in

provisional diagnosis. If there's pain, we need to classify whether it is reversible

or irreversible.

So, if there's no pain at all, no any PA involvement, the problem is confined to

the pulp, the pulp is non vital, so the diagnosis is necrotic pain.

So, the diagnosis of necrotic pulp is the tooth is not vital, asymptomatic and no

PA involvement at all in radiographically.

Why the pulp is necrotic? Of course it is not just spontaneous necrosis.

There's necrotic, because there's inflammation, and then irreversible inflammed

and then become necrosis. But these scenario maybe very slow, very chronic

without any symptom.

The patient comes with teeth of remaining roots. ** The teeth in the root are

hyperemia, pulpitis, pain with cold and hot.** So the patient is complaining no

history of pain, just the teeth keep breaking with the time. It is because the


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process is chronic in addition with personal factors and the pain threshold is

very high.

Necrotic pulp, it is maybe carious teeth and passes trough all these stages, can

be chronic and asymptomatic and maybe history of trauma, very long time ago

and then extreme/severe pain couple of days, but then the pain subsided.

Usually the patient thinks that the problem is solved. But actually the problem is

just started, become necrotic pulp.

When we do pulp testing, there's no respond, and it is asymptomatic and there's

no changes, except for sclerosing osteitis or increase bone deposition and this is

induced by pulp inflammation.

This is the same picture before, because necrotic pulp maybe it passes trough

the pulpitis, the reversible and irreversible but in a slow way without symptom.

SLIDE 30

Periapical pain is usually well localized as we said previously because

proprioceptors are involved. These are receptors to determine the location. And

usually it is deep pain, not just lacerating sharp pain. The patient feels pain in

the area, he can identify the tooth and it is like pain in the tooth and bone. It

may cause headache. It is deep pain, intensifies by chewing. Heat and cold do

not play a part here. The main provoking factor is mechanical factor like

chewing or biting on the tooth. It may have moderate to severe intensity based

on whether it is chronic or acute periapical.

SLIDE 31

In acute periapical periodontitis the pulp is impossibly normal because now we

are discussing periapical lesions induced by the pulpal problems. It should be at

least irreversibly inflamed. Even not only hyperemia or reversible pulpitis.

Usually we have either:


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irreversible pulpitis (because the apical part here started to go intodegenerative changes (1:25:54) to pass out through the apical foramen.)

or the pulp is necrotic. A3ad necrotic, asymptomatic ba3din balleshbacteria to pass through the apical foramen and create an infection in theperiapical area.

Clinically

Like we said, acute apical periodontitis can be clinically detected as a red

inflamed gingiva over the affected tooth. The early sign of periapical

periodontitis manifests as red inflamed gingiva which is tender to palpation.

This is very important when we (1:26:34) from the patient, (1:26:39)? Lamma

bikun acute periapical periodontitis? severe pain and I cannot bite on thattooth. Maybe if its very severe, I cant even touch this tooth. Touching the

tooth will cause problem.

These are the complaints from the patient: I cannot bite on this tooth, I

cannot eat on that side for three days, cannot bite, cannot touch and he will be

able to localize the tooth for you.

If the patient cannot determine the tooth, it means pulpal pain: reversible or

irreversible, (it depends on the severity and duration of the pain).

If the patient is able to localize the pain, it means proprioceptives are

involved and we are talking about periapical infection.

Radiographically

When you examine the tooth and it is tender to palpation or percussion, the

gingiva is red and inflamed, you know that it is a case of acute perapical

periodontitis. Then you want to confirm your diagnosis or to investigate itfurther. So, you took periapical radiograph which is a good decision, and you

dont see any changes at all periapically. It means that it is just at an early

stage, because there isnt enough time to initiate bone resorption. The bacteria

actually went to the periapical area and initiate an inflammatory response, so we

have pain. The proprioceptors are activated but still the osteoclasts are not

active to initiate bone resorption. So there are no changes at all periapically.

This shouldnt make you change your mind. If the patient comes after 2 or 3

days, you may see the lamina dura is still hazy, or started to become hazy and


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the periodontal space have slight widening which indicates the periapical

lesion has started.

Treatment

Again, the treatment of the tooth is RCT if its restorable or extraction if its

not.

Example

For example here, I made class II amalgam filling about 4 days ago. Then, the

tooth became painful and the pain increases in intensity about 2 days ago. He

couldnt sleep. It causes severe pain and now he even cannot touch the tooth. Itis tender to palpation and percussion.

When I take a radiograph, theres nothing but it seems that the irritation is

beyond the ability of the pulp to withstand. So, we have irreversible

inflammation. Quickly, see whats wrong with the canal? Blood. Previously the

pulp is in a good condition. From the beginning, there were slight changes. So

when I did cavity preparation, it added the pressure on the pulp so there was

degradation of the pulpand necrosis. Then the necrotic material went out

here(periapically).

The lamina dura is not clear, hazy, and the periodontal ligament has

minimal widening. So this is in the very early stages of acute apical

periodontitis.

This is an artifact: we see 2 lines of lamina dura sometimes, based on the angle

of the beam. One time the lamina dura is not showing, not because its not

present, but because of the angle. It seems mixed with the rest of the bone.


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Or like what you see here, sometimes it even seems more prominent like 2

radiopaque lines. So this artifact is based on the angle of the beam.

SLIDE 32

Acute apical abscess is exactly the same but the type of bacteria is either very

virulent or the immune defense is very bad. This will allow the formation of

abscess. Other than that, it is just exactly the same pathogenesis, clinical and

even radiographic presentation. The difference is that in acute apical

periodontitis, the bacteria have low virulence or stronger immune defense so it

will be presented as apical periodontitis, just inflammation. In acute apical

abscess, it will be abscess production. But the rest is exactly the same.

In acute apical abscess, if theres still no treatment, it will accumulate, trying to

find a way to get out by looking for the weakest tract. So it has its own tract to

get out as purules.

Now well see these cases.

SLIDE 33

I have a 14 year old female patient. Shes complaining ofsevere pain in the

whole upper anterior teeth. So the pain is poorly localized. She managed to

locate the upper anterior area but she cant determine which tooth.

The pain started 2 days ago, became severe last night and she woke up this

morning with swelling. It led to cellulitis.

She looks ill which means there is systemic involvement, she doesnt feel well

and looks dizzy.


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Intraoral Examination

When we did intraoral examination, we see localized swelling in the periapical

area which is painful, tender, fluctuant, and if we do drainage, pus and blood

will come out. Sometimes we do drainage just to remove the blood. This will

improve the prognosis and the treatment for the tooth.

We can see some carious teeth, they look okay but this swelling is over these

two teeth.

For the centrals, where does the pus come out? Most likely labial.

Usually the laterals drain the pus palatally.

These are just what usually happen but there may be variations. For instance intilting of the tooth or if the root has dilacerations, surely this will make a

difference.

Diagnosis when seen clinically

So clinically the diagnosis is: Acute (because she is ill) apical (clearly there is

periapical involvement, its not just pulpitis) abscess. We said that acute apical

abscess and periodontitis are exactly the same but if we see signs of abscess

here, I will know this is acute apical abscess.

The chronic apical periodontitis is a general term. Among this term we can

include chronic apical periodontitis. (I dont have any idea what this means???)

If we see abscess is oozing out from the pulp canal, from the cervix of the tooth

or I see fluctuations over the tooth, so I know it is acute apical abscess, not

acute apical periodontitis because I know it is an ABSCESS.

(1:39:33)?- (1:40:00)

Further investigations


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What are the methods of examination?

Visual examination (I did it), percussion, palpation.

When I did percussion, this tooth was tender.

Then what do I have to do? Radiograph.

Can I do vitality testing? Bas mumkin this tooth vital, I exclude this tooth,

right? So I want to do vitality testing.. (1:40:50) So this is non-vital, this is non-

vital, this is still vital (irreversibly inflamed: prolonged stimulus).

*Note: The vital tooth was the lateral incisor.

Were going to take radiograph to see what is going on.

Tooth 11:

The central looks badly broken. What should

we do? RCT. (1:41:33). We see poor oral

hygiene, here theres caries, there isnt any

periapical .. ,but here theres minimal PDL

widening (1:41:50) and we see external root

resorption (because the root should be up to

here but here the root looks shorter than the filling).

Tooth 12:

This tooth looks sound. We see composite filling. Some of the filling looks

radiolucent right? We see radiolucency here which is rarefying osteitis.

Tooth 22:

And how about this lateral? It also looks sound and there is composite filling.Inside there is radiolucency. So, what should I do? A student said put gutta

percha. Dr. said: Where should I insert the gutta percha point? Usually I will

insert it into an orifice which I can see. The lamina dura is lost in both teeth.

Diagnosis when seen radiographically

The condition of the patient is acute right? Because she has severe pain, abscess

is accumulating and we have systemic involvement. But when we see the

radiograph, it looks chronic because it takes a long time to have thisradiolucency.


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Why??

One of the possibility is this condition is an acute exacerbation of chronic

periodontitis.

SLIDE 33-CASE1

The lateral,u can see here a irreversibly inflame.This is tender to

percussion.Most likely cone lateral is the cause of infection.This shape of

radiolucency is associated previously with central incisor that have cyst.The

size quite big or maybe granulation tissue,ok.This is chronic

infection.Symptoms that happen here is acute.This lateral is irreversibly inflame

which mean active infection is going on.

For most likely,the symptom is irreversible inflammation,acute apical

periodontitis.(1:45:54)Reactivation of chronic infection.Patient cannot

recognize.We have here tender and this also tender.(1:46:10)We start from the

lateral with RCT.I need to do drainage.Usually if we have swelling around the

tooth we will do drainage.We do drainage here.We open the canal of the

lateral.We do RCT,extirpation of the pulp.This might be enough to relief a little

bit of symptoms.If the systemic involve we will give the antibiotics,analgesic

which is NSAID.

The definitive treatment,what should we do?This tooth need RCT,and this toothalso need RCT(central and lateral incisors).This tooth maybe we can do


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episectomy(surgical endodontics).The endodontist will decide if the tooth is

restorable or not(cent.incisor right)We have true root resorption too.This tooth

maybe hopeless.I need to treat both tooth endodontically and do drainage.What

the diagnosis of the lateral,it is irreversible pulpitis with acute apical

periodontitis or acute apical abscess.

SLIDE 35

This is very good guideline to prescribe medication.If the patient has mild pain

like throbbing,prescribe ibuprofen,200mg when needed and paracetamol if

NSAID is contraindicated.If the patient has moderate pain,ibuprofen 400mg

when needed,inadequate analgesia,ibu profen and revacod tab(Revanine andcodein).

Greater advantages if we give NSAID(peripheral acting) and we give

codein(centrally acting).If we give both drugs will give greater advantages.We

need to wait every 8 hours.The intensity of pain,better prescribe analgesic by

time not upon need.

In severe pain like acute apical periodontitis or acute apical abscess.The most

important part is management of pain.We hear first the chief complaint of the

patient.What is the prescription?Ibu Profen,400mg,every 6 hours,we need to

wait again.We deal with the pain by time.Starting immediately after dental

treatment.(1:51:06).Eat something and take 400mg every 6 hours.While

Revacod tab,every 8 hours,starting 2 hours after dental appointment.

Analgesic always present all the time in the blood stream.I'm mixing 2 types of

analgesia,which are peripheral acting(NSAID)and centrally acting(codein-

revacod).The time is not definite,We can give 1 day or 2 days after the dental

visit.If more days than that,the most severe pain,the patient will feel.That's

mean we can give analgesia the day of treatment and the day after.The patient

should judge his need for analgesia.Maybe the patient only use propaine(not

sure),the patient can use every 8 hours.(1:52:29).We give the prescription and

explain exactly to the patient how to use the medication.Analgesia that present

in the blood stream use to control the pain.The maximum dose of Ibu


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Profen,3.2g daily.This dose should be control by prescription.You should

inform the patient that the patient is taking very high dose of analgesia to

control the pain.You should not continue of this dose,only 1 or 2 days

maximum,then u should stop this regime and go to the moderate or mild

depending to situation of the patient,ok??3.2g is very high dose.U have power

to prescribe this medication or this high dose.

(U NEED TO MEMORIZE THIS AS U GONNA PRESCIBE THEM

FREQUENTLY)

SLIDE 36

We will go quickly to chronic apical periodontitis.Pain is very mild or

sometimes absent of pain.Most of the cases are just diagnose through theroutine of examination like when u are taking radiograph or when the patient

come to the clinic to do for the crown of particular tooth and upon examination

u find recurrent caries.U took radiograph and u notice the tooth have periapical

pathosis or rarefying osteitis and it is assymptomatic.You decided the diagnosis

of this tooth.

What is this? what your diagnosis?It has periapical pathosis,and see

radiolucency.Definitely this not confine to the pulp,it is confine to the

periapical.Is it acute or chronic?Answer:chronic.because asymptomatic.Whattreatment for this patient?Extraction or maybe we can do RCT.You should not

leaving it.Ethically it is not acceptable although the tooth is assymtomatic.The

patient may get other infection and cause acute exacerbation later on.


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SLIDE 38

This is another presentation for Periapical periodontitis.What u see

here?sclerosing osteitis.(lf pic)It is not always rarefying osteitis,it can be

sclerosing osteitis.U can see root caries here.(rt pic)U can see bifurcation

involvement.It has also rarefying osteitis and periapical involvement.All of this

are presentation of periapical periodontitis.

A student said the picture(lf pic)show malignant lesion as it is ill defined

radiolucency and give root resorption.DR answered:I didn't think that this is

diffuse lesion associated with malignant.We can see more bone between roots.

But here I can see heavily restored tooth.It Is asymptomatic(rt pic).We can see

radiolucency here.It is define that this is chronic apical periodontitis.

It can be chronic periapical abscess if I can see the evidence of abcess.

SLIDE 39

Complication of chronic PA Periodontitis can be osteomyelitis.The infection

just not be limited to periapical area of the tooth.It can spread to the bone.The

larynx could be weak because of infection and has abcess,malaise and fever.

The cases slide we will dicuss next lecture,ok.

Thank u.

ALL THE BEST FOR THE ORAL DIAGNOSIS EXAMS!!!:)))

SORRY FOR ANY MISTAKES.

BY:UMI ATTIYAH,ZAFIRAH HANI,NUR FARIHAH


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Oral Diagnosis 9