endo214

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emm64
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endo214
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2013-04-25 18:45:15
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endo214
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  1. pulpal diagnosis
    • alive: normal, reversible pulpitis, symptomatic  or asymptomatic irreversible pulpitis
    • dead: necrotic
  2. apical diagnosis
    • healthy: normal
    • unhealthy: SAP, AAP, AAA, CAA
    • Acute: new, symptomatic, early bone changes
    • chronic: pre-existing, mild, bony change
  3. Symptomatic irreversible pulpitis clues
    • spontaneous
    • woken up
    • lingering
    • heat sensitive
  4. palpation dianoses what?
    • inflammation through cortical plate
    • pinkie over root apex
    • not pulp test
  5. percussion tests what?
    • PDL inflammation (extension or infection)
    • use metal mirror handle
    • not pulp test
    • lateral percussion for fractures
  6. lateral percussion used for _____
    fractures
  7. mobility test:
    • periradicular or perio disease
    • root fracture
    • bruxism
    • use metal mirror handle w lateral force
    • 0: barely discernable
    • 1: less than 1mm
    • 2: more than 1mm & vertical displacement
  8. perio probing that are endo problems
    • narrow, deep, vertical, isolated
    • vs. broad, wide, generalized

    probe until blanced w/ local anesthesia
  9. cold test procedure
    • isolate & dry
    • incisal, middle, cervical
    • avoid gingiva
    • keep time
    • +: normal, short, hypersensitvity
    • -: could be necrotic
    • materials: endo ice (fluoromethane), ice stick, dry ice (CO2), ice water w/ rubber dam, ethyl chloride
  10. heat test procedure
    • isolate & dry
    • middle, cervical, not near gingiva
    • material: heated GP & vaseline, 
    • + hot H2O&dam is usually abnormal
    • not as useful
    • use for hx of heat sensitivity or inconclusive cold
  11. electric pulp procedure contraindicated for ____
    pacemaker
  12. electric pulp test
    • isolate & dry
    • middle/incisal thirds only
    • not near gingiva
    • tiny blob of toothpaste
    • slow increase (4.5)
    • +: <80 seconds
    • -: repeat at 5.5
    • false +: short cirucuit
  13. tests for cracks & fractures
    • transillumination
    • methylene blue: 
    • microscope
    • tooth slooth
  14. symptoms of cracks & fractures
    • cold sensitvity, tenderness on biting or pain on release.
    • J shaped radiographic lesion
    • narrow isolated vertical probing defect
    • fat post, big restoration, bruxing
  15. finding MB2
    • wide MB root
    • multiple xray angles
    • double PDL outlines
    • probe
    • know anatomy
    • dentinal map
    • illumination
    • magnification
  16. reversible pulpitis symptoms & tx
    • No spontaneous pain
    • Responsive to cold, heat, EPT
    • Short duration
    • Moderate severity

    • Monitor / reassure
    • No intervention
    • NSAID
    • Seal exposed dentin (GLUMA or Hurriseal, etc)
    • Caries removal & restoration
    • Replace defective restoration
    • Stop using acid drinks, sucking lemons, bleaching agents
  17. symptomatic irreversible pulpitis symptoms
    • Spontaneous pain, woken up
    • Responsive to cold, heat, EPT
    • Longer duration
    • Increased severity
    • +/- Periapical inflammation
  18. asymptomatic irreversible pulpitis
    • ● Vital inflamed pulp incapable of healing
    • ● No clinical symptoms
    • ● Inflammation from caries, caries excavation, trauma
    • Pulp exposed by caries, pulp polyp
    • Pulp exposure during operative procedure
    • Pulp exposure due to trauma
  19. pulp necrosis
    • Death of the pulp
    • ● Usually nonresponsive to testing (C-fibers, multicanal)
    • No pulpal pain
    • Nonresponsive to cold, heat, EPT
    • Prior history / record of responsiveness
  20. NORMAL  APICAL  TISSUES
    • ● Not sensitive to percussion or palpation
    • ● Lamina Dura is intact
    • ● PDL space is uniform
    • History  normal
    • Other  findings  from  comprehensive  eval  normal
    • No  Intervention
  21. SYMPT.   APICAL  PERIODONTITIS
    • ● Inflammation, usually of apical periodontium
    • ● Clinical symptoms
    • ● Pain to biting, percussion, and/or palpation
    • ● + Radiolucency
    • Very,  exquisitely,  sensitive  to  percussion,  biting
    • Sometimes  only  slight  PDL  space  thickening
    • + Prior history of pulpitis
    • Minor  occlusal  reduction
    • RCT
    • NSAID
  22. ASYMPT. APICAL PERIODONTITIS
    • ● Inflammation & destruction of apical periodontium
    • ● No clinical symptoms
    • ● Radiolucency present
    • Slightly sensitive or “different” to percussion, biting
    • Definite radiolucency present
    • Minor occlusal reduction
    • RCT
    • NSAID
  23. ACUTE APICAL ABSCESS
    • ● Inflammatory reaction to pulpal infection / inflammation
    • ● Rapid onset
    • ● Spontaneous pain
    • ● Tenderness of tooth to pressure
    • ● Pus formation
    • ● Swelling of associated tissues
    • Signs of infection, redness, fever
    • Minor occlusal reduction
    • RCT
    • NSAID
    • Antibiotics if: fever, systemic, spreading, airway
    • Drain & warm salt rinses if fluctuant swelling
    • Trephinate apical bone if needed for drainage
  24. CHRONIC APICAL ABSCESS
    • ● Inflammatory reaction
    • to pulpal infection / inflammation
    • ● Gradual onset
    • ● Little or no discomfort
    • ● Tenderness of tooth to pressure
    • ● Intermittent pus discharge through a sinus tract
    • Definite radiolucency
    • Trace sinus tract with GP X-ray
    • + prior history of swelling / drainage
    • Minor occlusal reduction
    • RCT
    • NSAID
  25. CONDENSING OSTEITITIS
    • ● Diffuse radiopaque lesion
    • ● Localized bony inflammatory reaction to a low-grade stimulus
    • ● Usually at tooth apex
    • ● Tenderness of tooth to pressure
    • Check pulpal diagnosis to confirm endodontic origin
    • Condensing osteitis may co-exist with other apical diagnoses
    • Minor occlusal reduction
    • RCT
    • NSAID
    • SNW
  26. LESION OF NON-ENDO ORIGIN
    • ● Do not forget this possibility
    • ● Exclude endo causes
    • ● PCD, benign causes, malignant causes
    • ● Normal anatomy eg mental foramen
    • ● Refer appropriately
  27. APICAL DIAGNOSIS SUMMARY
    • • NORMAL
    • • SYMPT APICAL PERIODONTITIS (SAP)
    • Very sensitive to percussion
    • Often slight thickening PDL space
    • •ASYMPT APICAL PERIODONTITIS (AAP)
    • PARL
    • Can be asymptomatic
    • Can have some percussion sensitivity
    • • ACUTE APICAL ABSCESS (AAA)
    • Clinical infection, swelling
    • Fever: use antibiotics
    • Fluctuant swelling: drain it
    • • CHRONIC APICAL ABSCESS (CAA)
    • Sinus tract & PARL
  28. FEVER, SWELLING
    • → AAA
    • → I & D
    • → Antibiotics
    • → Admit if airway affected
    • & don’t forget to do the RCT !
  29. SINUS TRACT, PATENT PARULIS
    • → CAA
    • → X-ray with GP cone to trace
  30. EXTREME COLD SENSITIVITY WITH PAIN ON BITING
    • → Often a cracked vital tooth
    • → Could be a rare SIP & SAP
  31. LOCATION OF PARL
    • Centered on cause of problem:
    • e.g. Root canal portal of exit
    • e.g. Lateral canal
    • e.g. Missed canal
    • e.g. Location of perforation
    • e.g. Location of fracture
    • Take off-angle films
    • SNW
  32. CRACKED TEETH
    • Isolated vertical probing defect(s)
    • “J” Shaped radiographic lesion
    • Posts increase the risk
    • Sensitivity on biting
    • Pain on release
    • “Tooth Slooth” positive on cusp(s)
    • Visualization by transillumination
    • Visualization by methylene blue stain
    • Visualization by flapping to expose root
    • Vizualization using miocroscope
  33. NON-RESPONSIVE to COLD, HEAT, EPT:
    • EITHER
    • NECROTIC,
    • OR
    • ALIVE and the patient just didn’t feel it.
    • CHECK: Was it previously responsive?
    • CHECK: ALL OTHER FINDINGS.
  34. Antibiotics are not effective in a root canal because
    inadequate systemic circulation
  35. Prophylactic Antibiotic Premedication (PAP) is recommended for patients of greatest risk of
    • high-morbidity outcomes of
    • Infective endocarditis
    • including:
    • Artificial heart valves
    • History of IE
    • Certain specific serious congenital heart conditions
  36. Indication of Use of Antibiotics in Endodontic Treatment
    • Systemic involvement
    • Persistent infection
    • Spreading infection
    • 1. Fever, malaise, celluitis, unexpected trismus
    • and progressive diffuse swelling, alone or in
    • combination, are signs and symptoms of
    • systemic involvement and spread of infection.
  37. When antibiotics are prescribed in conjuction with debridement of the root canal system and soft tissue drainage, significant improvement should be seen within
    48 hr
  38. penicillin regimen
    • effective against many of the bacteria found in
    • polymicrobial endodontic infections, including
    • anaerobes and Gram positive facultative
    • bacteria(streptococci and enterococci).
    • – About 10% of population may be allergic.
    • – An initial oral loading dose of 1000mg of penicillin
    • VK is followed by 500mg q6h for 7 days.
  39. clindamycin
    • Effective against many Gram positive and Gram
    • negative microorganisms including both facultative
    • and strict anaerobes.
    • – It is well distributed throughout the body and reaches
    • bone concentrations approaching that of plasma.
    • – Clindamycin therapy has been associated with
    • pseudomembranous colitis.
    • – The usual adult dose if 150mg to 300mg q6hr for 7
    • days.
  40. Metronidazole
    • – Bactericidal against anaerobes but does not have
    • activity against aerobes or facultative anaerobes.
    • – The addition of metronidazole to penicillin for a
    • serious endodontic infection, especially in a medically
    • compromised patient is appropriate.
    • – The recommended dosage for a patient with an
    • anaerobic infection is 250-500mg q6hr for 7 days
  41. which antibiotic combination is useful in endodontic infections?
    • Amoxicillin + Metronidazole
    • To combat ulcer causing H. pylori.
  42. Shaping
    via files facilitates cleaning & obturation
  43. irrigants
    clean system and reach inaccessible areas
  44. irrigant Properties
    • – Tissue or Debris solvent
    • – Toxicity
    • – Low Surface Tension
    • – Lubricant
    • – Sterilization (Disinfectant)
    • – Removal of Smear Layer
    • – Other
    • User Friendly
    • Cost
    • Shelf Life + Storage
    • common: NaOCl 5.25% (sodium hypochlorite), EDTA 15%, Hydrogen Peroxide 3%, CHX Gluconate
  45. Sodium Hypochlorite (NaOCl)
    • 5.25% - dilute with equal parts water (2.6%) just
    • as effective
    • Potent antimicrobial agent
    • Dissolved vital and nonvital tissues
    • pH 11.0-11.5
  46. RC Prep
    • – Glycerin base lubricant
    • – EDTA – chelator
    • – Urea peroxide
    • – Alternate with NaOCL – release Cl gas + O2 that will
    • eliminate bacteria and sanitize canal.
  47. Chlorhexidine Gluconate
    • 2%
    • Effective antimicrobial agent (Broad Spectrum)
    • Low toxicity
    • Not known to dissolve tissue
    • Alternative with NaOCl for greater antimicrobial
    • effect
  48. Calcium Hydroxide
    • Necrotic cases
    • Mixed with water or glycerin
    • Effective antimicrobial agent
    • High pH, 12.5
    • Takes 1 week in canal to be effective
    • Does not infuse into dentinal tubules
    • Pulp capping
    • Interappointment canal dressing
    • Apexification
  49. Intracanal medicaments
    • 2% Clindamycin – penetrates dentinal tubules
    • 2% Chlorhexidine gel – E. Faecalis

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