Pulp and Periapical Chapter 3

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Pulp and Periapical Chapter 3

• Also notes from biopsy techniques

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Teeth are non-vital
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Condensing Osteitis

• Two periapical films showing well defined
  radiopacity at apex of Mn 1st molar, exibits root
  tip absorption and loss of lamina dura and some
  widening of the PDL space. Both lesions are
  present on teeth with crown or extensive caries
• Differential
• Condensing osteitis--look for large carious
  lesion or crown (this is correct for previous 2
  radiographs)
• Idiopathic osteosclerosis (bone scar) (because
  the tooth is non-vital you can rule this
  out--Also note that the PDL space is rarely
  obliterated with bone scars
• Osteoma (a smaller lesion)--look for multiple
  impacted supernumerary teeth and odontomas--can
  tip you off to Garnders
• Periapical cemento-osseous dysplasia-- if pt. was
  female and african and pulp vital! (so this can
  be ruled out)
• Cementoblastoma--these can be differentiated by a
  thin radiolucent border and they generally show
  fusion to the root from which it arose
• Treatment
• Root canal therapy

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• Patient reports severe pain to heat extremes
• Spontaneous pain
• Response to Electric pulp test is erractic
• Onset has been about a week

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Irreversable Pulpitis

• Occlusal view and periapical radiograph of tooth
  14 showing enlarged pulp and occlusal mass
  protruding through the dentin
• Differential
• Irreversible pulpitis
• Periapical abcess-remember if you see a cyst at
  the apex it means that a cyst was there before
  the abcess--abcess is acute--it dosent have
  enough time to wear through the bone and make a
  well-defined radiolucency
• Treatment
• Endo
• extraction

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• Sensitive to heat extremes
• Pain goes away when thermal stimulus removed
• No spontaneous pain
• Responds at lower currents to electric pulp
  testing

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Reversible Pulpitis

• Differential-
• Reversible pulpitis
• Recurrent caries
• Treatment
• Remove agent that is causing the inflammation

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Note the white arrow
Radiograph of same tooth
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Periapical Abscess

• Tooth 3 has widened PDL on DB root, parulis (a
  result of purulent drainage) has collected near
  the apex of the DB root tip. No distinct
  radiolucency noted and pt reports acute onset
• Differential
• Scleroderma (systemic sclerosis) generalized
  widening of PDL
• Sarcoma or carcinoma
• Treatment
• Root canal therapy
• If the teeth are VITAL and you see any
  radioLUCENCY in the jaw you must biopsy!!

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Teeth are vital
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Idiopathic (focal) Osteosclerosis

• Differential
• Cemento-osseous dysplasia
• Complex odontoma
• Treatment
• None b/c its a radiopacity

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African woman, vital teeth
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Periapical cemento-osseous dysplasia

• Differential
• Complex odontoma
• Idiopathic osteosclerosis
• Treatment
• None, you dont worry about a biopsy b/c african
  and anterior MN

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• Pt has history of infected MN molar and/or root
  fracture airway obstruction

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Ludwigs Angina

• Swelling of the submandibular, submental and
  sublingual spaces with resulting airway
  obstruction
• Differential
• Thyroid gland enlargement, Thyroglossal duct
  cyst, dermoid cyst
• Treatment
• Aggressive use of antibiotics, drainage, in some
  pts may need to perform tracheostomy

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Cavernous Sinus Thrombosis

• Grave concern is raised when the infection
  encroaches on the eyelid or affects vision,
  because the ophthalmic (angular) veins lack
  valves and spread of infection to the brain is
  possible
• Treatment
• drainage, antibiotics, high mortality rate

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Teeth are vital
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Periapical cyst or Granuloma

• Loss of lamina dura around effected roots
• Differential
• Impossible to tell difference b/w cyst or
  granuloma from radiograph alone--need biopsy
  (cysts are the result of cell rests of Malassez
  being in the area of inflammation)
• Periapical scar-radiolucency will persist if scar
  is formed
• If on the side of root (not at apex) then lateral
  radicular cyst
• Treatment
• Root canal therapy with follow up to make sure
  the lesion has healed

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Biopsy techniques

• Get normal tissue with abnormal tissue
• If surface lesion--dont need to go too deep
• If swelling or mass--the deeper the better
• Dont biopsy the middle of an ulcer
• Lasso technique
• Mark with sutures
• Punch biopsy--5mm minimum
• Include picture and differential with as much
  clinical info as possible--this is very important
• Contact the pt right away with results!!

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Traumatic (simple) bone cyst

• Not a true cyst posterior mandible asymptomatic
  or painless swelling
• X-ray well-defined unilocular radiolucency
  scalloped appearance in multiple teeth
  involvement
• Histo fibrovascular CT trabecular bone cyst
  may be empty
• Tx surgical exploration tissue submission
  good prognosis, rapid new bone formation
• DD periapical granuloma, periapical cyst,
  periapical cemento-osseous dysplasia, periapical
  scar, dentin dysplasia type 1 (page 804)

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Granular Cell Tumor-no diff. diagnosis in
book-nodular mass under skin or mucosa-tongue
and buccal muscoa-schwann cell origin or
neuroendocrine cellstx local excision
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Allergic Stomatitis Dentifrice
Stomatitis-pseudomembranous candidiasis,
morsicatio, sloughing traumatic lesion,
mouthwash, chemical burn-burning, slight redness
to brilliant erythematous lesion, edema possible,
superficial aphthous ulcerations possible,
stinging tingling, superficial epithelial
sloughing-located at site of contact-dentifrice,
medications, lip stick, metals-tx remove
allergen, antihistamines if necessary
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Angioedema-no diff. Dx listed in book-diffuse
edematous swelling of soft tissue, nontender,
solitary or multiple-face, lips, tongue,
pharynx, larynx, hands, arms, legs, genitals,
buttocks-cause mast cell degranulation which
leads to histamine release and typical IgE
hypersensitivity reaction from drugs, foods,
plants, dust, heat cold, stress, complement
cascade is common in hereditary andioedema-tx
oral antihistamines, intramuscular epi,
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