Oral Diagnosis 9
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Transcript of 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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