DISEASES OF
PULPAL &
PERIRADICULAR
TISSUE…
1
ADITI SINGH
P.G DEPT. OF PEDODONTICS
SDCH
THE HERO----PULP
THE PROBLEM---DISEASES OF PULP
SIDEKICKS----PERIRADICULAR TISSUE
THE PROBLEM PART 2 ---DISEASES OF PERIRA...
THE HERO
3
The dental pulp is a delicate soft connective tissue interspersed
with tiny blood vesels,lymphatics ,myelinated & unmyelin...
The problem
5
CLASSIFICATIONS….
Abbott, PV,Yu C;A clinical classification of the status of the pulp and the
root canal system;Australian...
Weine Ingle Cohen & Burns
Normal pulp not
mentioned
Healthy pulp Normal not mentioned
Pulpitis
Hyperalgesia
Hypersensitive...
REVERSIBLE
ASYMPTOMATIC
SYMPTOMATIC
IRREVERSIBLE
ACUTE/
SYMPTOMATIC
CHRONIC
ASYMPTOMATIC
HYPERPLASTIC
INTERNAL
RESORPTION
...
Its not a disease but a
symptom
 mild to moderate
inflammatory
condition of pulp caused by
noxious stimuli
 pulp is cap...
 Causes
 agent capable of
injuring pulp like:
• trauma
• disturbed occlusal relationship
• thermal shock
•Carious lesion...
 Clinical Features
 sharp pain lasting for
a moment
 often brought on by cold
than hot food or beverages
and by cold ai...
 Clinical Features
 does not continue
when the cause has been
removed
 tooth responds to electric
pulp testing at lower...
Treatment
Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.
 Removal of noxious stimulus
Prevention
Early filling of cariou...
earliest form
 also known as pulp hyperemia
 excessive accumulation of
blood within pulp tissue
 leads to vascular con...
 Clinical Features
 sensitive to thermal
changes
 particularly to cold
 application of ice or cold
fluids to tooth res...
 Clinical Features
 disappears upon removal
of thermal irritant or
restoration of normal
temperature
 responds to elect...
 Clinical Features
 indicates lower pain
threshold than that of
adjacent normal
teeth
Cohen S,Burns RC; Pathways of Pulp...
 Clinical Features
 teeth show:
• deep carious lesion
• large metallic restoration
• restoration with defective
margins
...
 persistent inflammatory
condition of pulp
 may be symptomatic or
asymptomatic
 caused by noxious stimulus
IRREVERSIBLE...
 Causes
 bacterial involvement of
pulp through caries
 chemical
 thermal
 mechanical injury
20Cohen S,Burns RC; Pathw...
 Clinical Features
Early Stage
 paroxysm of pain
caused by:
• sudden temperature
changes like cold,
sweet, acid foodstuf...
 Clinical Features
Early Stage
 pain often continues
when cause has been
removed
 may come and go
spontaneously
Cohen S...
 Clinical Features
Early Stage
 pain
• sharp
• piercing
• shooting
• generally severe
Cohen S,Burns RC; Pathways of Pulp...
 Clinical Features
Early Stage
 pain
• bending over exacerbates pain which
• lying down is due to change in
• change of ...
 Clinical Features
Late Stage
 pain
• more severe as if tooth is under
• throbbing constant pressure
Cohen S,Burns RC; P...
 Clinical Features
Late Stage
 pain
• patient is often awake
at night due to pain
• increased by heat and
sometimes reli...
Reversible Pulpitis Irreversible Pulpitis
 pain is generally traceable
to a stimulus
 cold water
 air
 more severe
 l...
 extensive acute inflammation
of pulp
 frequent sequel of focal
reversible pulpitis
ACUTE PULPITIS
Cohen S,Burns RC; Pat...
 Causes
 tooth with large carious
lesion
 defective restoration
where there has been
recurrent caries
 pulp exposure d...
 Clinical Features
 severe pain is elicited by
thermal changes
 pain persists even after
thermal stimulus
disappears or...
 Clinical Features
 may be continuous
 intensity may be increased
when patient lies down
 application of heat may
may ...
 Clinical Features
 tooth reacts to electric
pulp vitality tester at a
lower level of current
than adjacent normal
teeth...
 pressure increases
because of lack of
escape of inflammatory
exudate
 rapid spread of
inflammation
through pulp with pa...
 may develop with or
without episodes of
acute pulpitis
 many pulps under large
carious cavities die painlessly
 1st in...
 Clinical Features
 dull aching type
 more often intermittent
than continuous
MANAGEMENT : endodontic therapy
Cohen S,B...
 also called as pulp polyp
or pulpitis aperta
 essentially an excessive
exuberant proliferation
of chronically inflamed
...
 pulpal inflammation due
to an extensive carious
exposure of a young pulp
 development of granulation
tissue
 covered a...
 Causes
 slow progressive
exposure of pulp
 bacterial infection
Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.
38
 Clinical Features
 most commonly involved
are deciduous molars +
1st permanent molar
• excellent blood supply
• large r...
 Clinical Features
 asymptomatic
 seen only in teeth of children
+ young adults
Cohen S,Burns RC; Pathways of Pulp; 6Ed...
 Clinical Features
 polypoid tissue appears
• fleshy
• reddish pulpal mass
filling most of pulp
chamber or cavity or
eve...
 Clinical Features
• sometimes, if mass is
large enough interferes
with closure of mouth
Cohen S,Burns RC; Pathways of Pu...
 Clinical Features
• may cause discomfort
during mastication
due to pressure of food
bolus
Cohen S,Burns RC; Pathways of ...
 Clinical Features
• tissue easily bleeds
because of rich network
of blood vessels
• tooth may or may not
respond at all ...
PULP POLYP Vs GINGIVAL
POLYP
PULP POLYP
1.Soft edematous more reddish in
appearance
2.Friable
3. On passing a probe around...
elimination of polypoid tissue followed by
extirpation of pulp
 hyperplastic tissue bleeding
can be controlled by pressu...
 death of pulp
 may be partial or total
depending on whether part
or the entire pulp is
involved
PULP NECROSIS
Cohen S,B...
 Causes
 sequelae of inflammation
 can also occur following
trauma
• pulp is destroyed before
an inflammatory reaction
...
 Types
 (1) Coagulation Necrosis
 (2) Liquefaction Necrosis
Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.
49
 Types
 (1) Coagulation Necrosis
• soluble portion of
tissue is precipitated or converted into a solid
material
Cohen S,...
 Types
 (1) Coagulation Necrosis
• tissue is converted into
tissue mass consisting
chiefly of coagulated
 proteins
 fa...
 Types
 (2) Liquefaction Necrosis
• results when proteolytic
enzymes convert the
tissue into softened mass
liquid or amo...
 Clinical Features
 no painful symptoms
 discoloration of tooth
• 1st indication that the pulp
is dead
Cohen S,Burns RC...
 Clinical Features
 history of pain lasting from
a few minutes to a few
hours followed by
complete + sudden
cessation of...
1.A mixture of the signs and symptoms of both pulpitis
and necrosis with infection.
2.mild with intermittent painful episo...
Incomplete fracture of a vital posterior tooth that
involves the dentine and occasionally extends into
the pulp.
CRACKED T...
Etiology..
Lynch CD,McConnell RJ; The Cracked Tooth Syndrome; J Can Dent Assoc 2002;
68(8):470-5 57
Treatment…
Lynch CD,McConnell RJ; The Cracked Tooth Syndrome; J Can Dent Assoc 2002;
68(8):470-5
Large central crack
No pu...
Barodontalgia is a symptom rather than a pathological condition
Its defined as an oral (dental or nondental) pain caused b...
• Cementing of fixed prosthesis with resin cements for
• patients
• Endodontically treated teeth that have been open for
e...
Barotrauma in flight Vs in diving
In flight the theoretically possible
pressure changes range from 1 atm
(at ground level)...
THE SIDEKICKS..
62
The periradicular tissue comprises of
surroundin Alveolar bone,
periodontal ligament & cementum.
PERIRADICULAR TISSUE
Cohe...
CLASSIFICATION..• Acute alveolar abscess
• Acute apical periodontitis
Acute periradicular disease
• Chronic alveolar absce...
K 04.4 : Acute apical periodontitis
K 04.5 : Chronic apical periodontitis (apical granuloma)
K 04.6 : Periapical abscess w...
PERIAPICAL PATHOLOGY
Symptomatic apical periodontitis (acute apical periodontitis):
a painful response to biting and percu...
ACUTE Vs CHRONIC
gradual onset, little or
no discomfort, and the
intermittent discharge of
pus through an
associated sinus...
An acute apical abscess may result when large numbers of
bacteria get past the apex and elicit a severe inflammatory
respo...
CLINICAL MANIFESTATION
varying degrees of swelling occur, with pain.
The patient complains of a feeling that the tooth is ...
• Acute osteomyelitis can arise directly from an endodontic
infection.
• Live bacteria are past the apex and now are multi...
CLINICAL MANIFESTATION
• The patient usually has severe pain, an elevated temperature,
and palpable lymph nodes.
• Althoug...
TREATMENT
Hyperbaric oxygen
Endodontic therapy or extraction of the carious tooth
More surgical treatment may be required
...
• An apical lesion that has established drainage through a sinus
tract is termed suppurative inflammation
CLINICAL MANIFES...
• A foreign body response may occur to many types of
substances.
• The reaction can be acute and/or chronic
• These lesion...
• The inflammatory response depends on the quality, duration,
and virulence of the irritant.
• A very low-grade, subclinic...
• This is a chronic inflammatory lesion that has epithelium lining
the lumen, but the lumen has a direct communication wit...
Antibioma is a sterile, chronic abscess formed because of
incomplete treatment of an infection by using antibiotics withou...
THE STORY
78
CASE HISTORY
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
MEDICAL HISTORY
DENTAL HISTORY
DRUG HISTORY
79
PAIN
MODE OF ONSET : Spontaneous or provoked
FREQUENCY & DURATION : continuous or intermittent
QUALITY OF PAIN :
Dull achi...
TYPE OF PAIN
Momentary pain
Persistent pain
Spontaneous pain
Provoked pain
81
EXTRAORAL EXAMINATION
Facial symmetry
Lymph nodes
TMJ
82
INTRAORAL EXAMINATION
SOFT TISSUSE EXAMINATION
Swelling
Discoloration
Sinus formation
Gingival inflammation
83
VISUAL EXAMINATION
Mobility in primary tooth may be physiological or pathological
WYMAN’S INDEX : 0:horizontal <0.2mm
1 : ...
PERCUSSION : can be checked by applying finger pressure on
the tooth or tapping with tip end of handle of the mirror ; if ...
PULP TESTING
Thermal Test : Heat Test / Cold Test
No Response
Mild – Moderate response that subsides in 1-2 sec
Strong Mom...
ELECTRIC PULP TESTING
False positive response :
improper isolation,
liquefactive necrosis of
pulp,apprehensive patient,
el...
Jacobson reported that the optimal placement of the probe tip in
vitro was the occlusal two-thirds on the labial or buccal...
• Thermal pulp testing depends on the outward and inward
movement of the dentinal fluid, whereas electric pulp testing
dep...
• The A-delta fibres are more affected by the reduction of pulpal
blood flow than the C fibres because the A-delta fibres ...
Percussion Testing is most reliable in primary teeth. (C Delta
fibres)
Thermal sensitivity Testing & Electrical Pulp Testi...
RADIOGRAPHIC
INTERPRETATION
Pathologic bone
resorption.
The bone destruction is seen in
the furcation area of the tooth.
T...
Pathologic root
resorption.
Commonly associated with
pathologic bone resorption .
Internal/External
resorption.
It will pr...
Calcific changes. Calcified bodies (known as calcific masses or
globules) present in the pulp indicate advanced pulpal
deg...
HISTOLOGY Vs RADIOGRAPHY
HISTOLOGIC APPEARANCE RADIOGRAPHIC FEATURES
Incipient apical periodontitis Bone structural change...
PERIAPICAL INDEX SCORING
rstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radiographic96
Normal pulp Reversible
pulpitis
Irreversible
pulpitis
Asymptoma
tic
Irreversible
pulpitis
symptomati
c
Pulp
necrosis
signs...
Normal
periapex
Symptomatic
AP
Asymptomati
c AP
Acute apical
abscess
Chronic
apical
abscess
Patient history none Pain when...
Anesthetic testing
(Grossman 1978) Source of
pain may be identified by
giving intraligamentary
anesthetic when all other
t...
WHAT’S NEW…?
100
Photoplethysmography
• Passing of light through the tooth & measuring existing
wavelength using galvanometer.Vital pulp wi...
• It is a method independent of a pulsatile circulation. The
presence of arterioles rather than arteries in the pulp and i...
• Teeth with vital pulps fluoresced normally but the teeth with
necrotic or absent pulps do not fluoresce when exposed to
...
• Xeroradiography is an electrostatic process which uses an amorphous
selenium photoconductor material, vacuum deposited o...
TOOTH TEMPERATURE
Hugeyes Probeye Camera : it can record temperature changes as
small as 0.1oC.it requires thermal video s...
Pulse Oximetry uses red and infrared
wavelengths in order to transilluminate a
tissue and detects absorbance peaks due
to ...
LASER DOPPLER FLOWMETRY
• Doppler frequency shift
• The fraction of light that is
scattered back from the
illuminated area...
Transillumination (using Fibreoptic
light)
Incomplete crack in the tooth (greenstick fractures)
Pulp vitality in anterior ...
• The device uses a transducer (a crystal containing probe), a
coupling agent and software with customized electronic and ...
• When applied to US examination, Color Power Doppler
flowmetry allows the presence and direction of the blood flow
within...
MRI
Best resolution of tissue of low inherent contrast
No ionizing radiations involved
Direct multiplanar image is possibl...
Cholesteric liquid crystals
Cholesteric crystals are a type of ‘liquid’ crystal, i.e. ordered fluids,
with a helical struc...
• 3D volume of data is acquired in the course of a single sweep
of the scanner, using a simple, direct relationship betwee...
114
Based on tomosynthesis (Webber & Messura 1999).
A series of 8–10 radiographic images are exposed atdifferent
projection ge...
• Given radiographs taken in precisely the same position
and with the same beam geometry and exposure parameters,
images c...
In a nutshell…
117
REFERENCES
McDonald RE,Avery DR,Dean JE;Dentistry for the Child and Adolescent;2012;9Ed;Elsevier
Ingle JE,Bakland LE, Baum...
Keir DM, Walker WA III Schindler WG, Dazey SE. Thermally induced
pulpalgia in endodontically treated teeth. J Endod 1991;1...
120
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Pulpal & periradicular diseases & their diagnosis

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Pulpal & periradicular diseases & their diagnosis

  1. 1. DISEASES OF PULPAL & PERIRADICULAR TISSUE… 1 ADITI SINGH P.G DEPT. OF PEDODONTICS SDCH
  2. 2. THE HERO----PULP THE PROBLEM---DISEASES OF PULP SIDEKICKS----PERIRADICULAR TISSUE THE PROBLEM PART 2 ---DISEASES OF PERIRADICULAR TISSUE THE STORY---DIAGNOSIS OF PULP DISEASES INTERVAL --- CONCLUSION CONTENTS 2
  3. 3. THE HERO 3
  4. 4. The dental pulp is a delicate soft connective tissue interspersed with tiny blood vesels,lymphatics ,myelinated & unmyelinated nerves & undifferentiated connective tissue cells that supports the dentin. PULP Chandra SB,Gopikrishna V;Grossman’s Endodontic Practice 12 Ed; 2010;Wolters Kluver 4
  5. 5. The problem 5
  6. 6. CLASSIFICATIONS…. Abbott, PV,Yu C;A clinical classification of the status of the pulp and the root canal system;Australian Dental Journal Supplement 2007;52:(1 Suppl):S17-S31 WHO AAE glossary Normal pulp not mentioned Normal pulp not mentioned Pulpitis : Initial (hyperaemia Acute suppurative Chronic (ulcerative / hyperplastic) Other unspecified pulpitis Pulpitis : Reversible Irreversible Pulp necrosis Pulp Necrosis Pulp degeneration : Denticles Calcification Stones Abnormal hard tissue formation in pulp Secondary or irregular dentin 6
  7. 7. Weine Ingle Cohen & Burns Normal pulp not mentioned Healthy pulp Normal not mentioned Pulpitis Hyperalgesia Hypersensitive dentin Hyperemia Painful pulpitis (Acute, Chronic) Nonpainful pulpitis (Chronic ulcerative , Chronic pulpitis, Chronic hyperplastic Pulpitis: Hyper-reactive pulpalgia Hypersensitivity Hyperaemia Acute pulpalgia Chronic pulpalgia Hyperplastic pulposis Pulpitis: Reversible Irreversible Asymptomatic Hyperplastic Internal resorption Canal calcification Symptomatic Pulp Necrosis Pulp necrosis Necrosis (Partial or complete) Pulp Degeneration Pulp degeneration Internal resorption Internal resorption Abbott, PV,Yu C;A clinical classification of the status of the pulp and the root canal system;Australian Dental Journal Supplement 2007;52:(1 Suppl):S17-S31 7
  8. 8. REVERSIBLE ASYMPTOMATIC SYMPTOMATIC IRREVERSIBLE ACUTE/ SYMPTOMATIC CHRONIC ASYMPTOMATIC HYPERPLASTIC INTERNAL RESORPTION PULP DEGENERATION CALCIFIC OTHERS PULP NECROSIS THE CLASSIFICATION… Chandra SB,Gopikrishna V;Grossman’s Endodontic Practice 12 Ed; 2010;Wolters Kluver Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 8
  9. 9. Its not a disease but a symptom  mild to moderate inflammatory condition of pulp caused by noxious stimuli  pulp is capable of returning to un-inflammed state following removal of stimuli REVERSIBLE PULPITIS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. Chandra SB,Gopikrishna V;Grossman’s Endodontic Practice 12 Ed; 2010;Wolters Kluve 9
  10. 10.  Causes  agent capable of injuring pulp like: • trauma • disturbed occlusal relationship • thermal shock •Carious lesion Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. Chandra SB,Gopikrishna V;Grossman’s Endodontic Practice 12 Ed; 2010;Wolters Kluve 10
  11. 11.  Clinical Features  sharp pain lasting for a moment  often brought on by cold than hot food or beverages and by cold air Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. Chandra SB,Gopikrishna V;Grossman’s Endodontic Practice 12 Ed; 2010;Wolters Kluve 11
  12. 12.  Clinical Features  does not continue when the cause has been removed  tooth responds to electric pulp testing at lower current Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. Chandra SB,Gopikrishna V;Grossman’s Endodontic Practice 12 Ed; 2010;Wolters Kluve 12
  13. 13. Treatment Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.  Removal of noxious stimulus Prevention Early filling of carious lesion Periodic care 13
  14. 14. earliest form  also known as pulp hyperemia  excessive accumulation of blood within pulp tissue  leads to vascular congestion FOCAL REVERSIBLE PULPITIS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 14
  15. 15.  Clinical Features  sensitive to thermal changes  particularly to cold  application of ice or cold fluids to tooth result in pain Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 15
  16. 16.  Clinical Features  disappears upon removal of thermal irritant or restoration of normal temperature  responds to electrical test stimulant at lower level of current Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 16
  17. 17.  Clinical Features  indicates lower pain threshold than that of adjacent normal teeth Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 17
  18. 18.  Clinical Features  teeth show: • deep carious lesion • large metallic restoration • restoration with defective margins MANAGEMENT : Removal of noxious stimulus before the pulp is severely damaged. Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 18
  19. 19.  persistent inflammatory condition of pulp  may be symptomatic or asymptomatic  caused by noxious stimulus IRREVERSIBLE PULPITIS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 19
  20. 20.  Causes  bacterial involvement of pulp through caries  chemical  thermal  mechanical injury 20Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.
  21. 21.  Clinical Features Early Stage  paroxysm of pain caused by: • sudden temperature changes like cold, sweet, acid foodstuffs. Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 21
  22. 22.  Clinical Features Early Stage  pain often continues when cause has been removed  may come and go spontaneously Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 22
  23. 23.  Clinical Features Early Stage  pain • sharp • piercing • shooting • generally severe Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 23
  24. 24.  Clinical Features Early Stage  pain • bending over exacerbates pain which • lying down is due to change in • change of position intrapulpal pressure Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 24
  25. 25.  Clinical Features Late Stage  pain • more severe as if tooth is under • throbbing constant pressure Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 25
  26. 26.  Clinical Features Late Stage  pain • patient is often awake at night due to pain • increased by heat and sometimes relieved by cold, although continued application of cold may intensify pain MANAGEMENT : Endodontic therapy Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 26
  27. 27. Reversible Pulpitis Irreversible Pulpitis  pain is generally traceable to a stimulus  cold water  air  more severe  lasts longer  pain may come without any apparent stimulus REVERSIBLE Vs IRREVERSIBLE PULPITIS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 27
  28. 28.  extensive acute inflammation of pulp  frequent sequel of focal reversible pulpitis ACUTE PULPITIS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 28
  29. 29.  Causes  tooth with large carious lesion  defective restoration where there has been recurrent caries  pulp exposure due to faulty cavity preparation 29
  30. 30.  Clinical Features  severe pain is elicited by thermal changes  pain persists even after thermal stimulus disappears or has been removed Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 30
  31. 31.  Clinical Features  may be continuous  intensity may be increased when patient lies down  application of heat may may cause acute exacerbation of pain Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 31
  32. 32.  Clinical Features  tooth reacts to electric pulp vitality tester at a lower level of current than adjacent normal teeth Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 32
  33. 33.  pressure increases because of lack of escape of inflammatory exudate  rapid spread of inflammation through pulp with pain + necrosis Management : endodontic therapy Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 33
  34. 34.  may develop with or without episodes of acute pulpitis  many pulps under large carious cavities die painlessly  1st indication is then development of periapical periodontitis, either with pain or seen by chance in radiograph CHRONIC PULPITIS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 34
  35. 35.  Clinical Features  dull aching type  more often intermittent than continuous MANAGEMENT : endodontic therapy Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 35
  36. 36.  also called as pulp polyp or pulpitis aperta  essentially an excessive exuberant proliferation of chronically inflamed dental pulp tissue CHRONIC HYPERPLASTIC PULPITIS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 36
  37. 37.  pulpal inflammation due to an extensive carious exposure of a young pulp  development of granulation tissue  covered at times by epithelium  resulting from long standing low grade infection Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 37
  38. 38.  Causes  slow progressive exposure of pulp  bacterial infection Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 38
  39. 39.  Clinical Features  most commonly involved are deciduous molars + 1st permanent molar • excellent blood supply • large root opening Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 39
  40. 40.  Clinical Features  asymptomatic  seen only in teeth of children + young adults Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 40
  41. 41.  Clinical Features  polypoid tissue appears • fleshy • reddish pulpal mass filling most of pulp chamber or cavity or even extend beyond confines of tooth Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 41
  42. 42.  Clinical Features • sometimes, if mass is large enough interferes with closure of mouth Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 42
  43. 43.  Clinical Features • may cause discomfort during mastication due to pressure of food bolus Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 43
  44. 44.  Clinical Features • tissue easily bleeds because of rich network of blood vessels • tooth may or may not respond at all to thermal test Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 44
  45. 45. PULP POLYP Vs GINGIVAL POLYP PULP POLYP 1.Soft edematous more reddish in appearance 2.Friable 3. On passing a probe around the polyp we can trace its origin within the tooth 4.Endodontic therapy or extraction in case of hopeless prognosis GINGIVAL POLYP 1.Comparitively firm with color similar to that of adjacent gingiva ( unless secondarily traumatized or inflamed) 2.Non friable 3. On passing a probe around the polyp we can trace its origin around or adjacent to the tooth 4.Remove the etiology for eg. calculus around the tooth 45
  46. 46. elimination of polypoid tissue followed by extirpation of pulp  hyperplastic tissue bleeding can be controlled by pressure  extraction of tooth can also be done MANAGEMENT Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 46
  47. 47.  death of pulp  may be partial or total depending on whether part or the entire pulp is involved PULP NECROSIS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 47
  48. 48.  Causes  sequelae of inflammation  can also occur following trauma • pulp is destroyed before an inflammatory reaction Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 48
  49. 49.  Types  (1) Coagulation Necrosis  (2) Liquefaction Necrosis Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 49
  50. 50.  Types  (1) Coagulation Necrosis • soluble portion of tissue is precipitated or converted into a solid material Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 50
  51. 51.  Types  (1) Coagulation Necrosis • tissue is converted into tissue mass consisting chiefly of coagulated  proteins  fats  water Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 51
  52. 52.  Types  (2) Liquefaction Necrosis • results when proteolytic enzymes convert the tissue into softened mass liquid or amorphous debris Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 52
  53. 53.  Clinical Features  no painful symptoms  discoloration of tooth • 1st indication that the pulp is dead Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 53
  54. 54.  Clinical Features  history of pain lasting from a few minutes to a few hours followed by complete + sudden cessation of pain MANAGEMENT : Endodontic therapy Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 54
  55. 55. 1.A mixture of the signs and symptoms of both pulpitis and necrosis with infection. 2.mild with intermittent painful episodes over many weeks or months. 3.Pulp sensitivity test results are mixed and frequently inconclusive or inconsistent with the patient’s description of symptoms. 4.Teeth with necrobiosis may also have apical periodontitis with radiographic evidence of a widened periodontal ligament space, which may be unexpected because the patient has reported sensitivity to hot and/or cold stimuli. NECROBIOSIS Abbott, PV,Yu C;A clinical classification of the status of the pulp and the root canal system;Australian Dental Journal Supplement 2007;52:(1 Suppl):S17- S31 55
  56. 56. Incomplete fracture of a vital posterior tooth that involves the dentine and occasionally extends into the pulp. CRACKED TOOTH SYNDROME (Cameron 1964) Lynch CD,McConnell RJ; The Cracked Tooth Syndrome; J Can Dent Assoc 2002; 68(8):470-5 56
  57. 57. Etiology.. Lynch CD,McConnell RJ; The Cracked Tooth Syndrome; J Can Dent Assoc 2002; 68(8):470-5 57
  58. 58. Treatment… Lynch CD,McConnell RJ; The Cracked Tooth Syndrome; J Can Dent Assoc 2002; 68(8):470-5 Large central crack No pulp involvement Immediate temporary Stabilization Permanent stabilization Bonded restoration or cast metal restoration Pulp involvement Immediate stabilization + pulp extirpation Monitor symptoms & complete RCT Hopeless prognosis extract Small peripheral crack Remove compromised portion Restore with composite or appropriate cast metal restoration 58
  59. 59. Barodontalgia is a symptom rather than a pathological condition Its defined as an oral (dental or nondental) pain caused by a change in barometric pressure in an otherwise asymptomatic organ.(Zadik Y ) CLASSIFICATION : (FDI) BARODONTALGIA 59
  60. 60. • Cementing of fixed prosthesis with resin cements for • patients • Endodontically treated teeth that have been open for endodontic treatment and temporarily sealed have been report to be explode on deep sea diving known as Odontocrexis, • full porcelain crowns have been reported to shatter at a dive of 65 ft, hence meticulous oral health advice should be given to the divers, • all carious lesions should be restored, all ill fitting crowns should be replaced with a good cementing medium, • active periodontal lesion treatment and completion of endodontic treatment should be done. • Also removable dentures are not recommended rather a FPD or an implant is indicated. MANAGEMENT Gaur TK, Shrivastava: Barodontalgia: A Clinical Entity J Oral Health Comm Dent 2012;6(1)18-20 60
  61. 61. Barotrauma in flight Vs in diving In flight the theoretically possible pressure changes range from 1 atm (at ground level) to 0 atm (at outer space) Possible mechanism of barotrauma 1.Direct ischaemia resulting from inflammation itself 2. Indirect ischaemia resulting from intra-pulpal increased pressure as a result of vasodilatation and fluid diffusion to the tissue 3. The result of intra-pulpal gas expansion.The gas is a by-product of acids, bases, and enzymes in the inflamed tissue 4. The result of gas leakage through the vessels because of reduced gas solubility In diving the changes are more significant, since each descent of 10 meters (32.8 feet) elevates the pressure by 1 atm. The most common way for air from the pressurized tanks to enter a tooth is by being forced in through carious lesions or defective margins As atmospheric pressure decreases during ascent, trapped gases may expand and enter dentin tubules, thereby stimulating nociceptors in the pulp or causing the movement of pulp chamber contents through the apex of the tooth, also causing pain 61
  62. 62. THE SIDEKICKS.. 62
  63. 63. The periradicular tissue comprises of surroundin Alveolar bone, periodontal ligament & cementum. PERIRADICULAR TISSUE Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 63
  64. 64. CLASSIFICATION..• Acute alveolar abscess • Acute apical periodontitis Acute periradicular disease • Chronic alveolar abscess • granuloma • cyst Chronic periradicular disease Condensing osteitis External root resorption Non endodontic origin Chandra SB,Gopikrishna V;Grossman’s Endodontic Practice 12 Ed; 2010;Wolters Kluver 64
  65. 65. K 04.4 : Acute apical periodontitis K 04.5 : Chronic apical periodontitis (apical granuloma) K 04.6 : Periapical abscess with sinus K 04.60: periapical abscess with sinus to maxillary antrum K 04.61 : periapical abscess with sinus to nasal cavity K 04.62 : periapical abscess with sinus to oral cavity K 04.63 : periapical abscess with sinus to skin K 04.7 : periapical abscess without sinus K 04.8 : radicular cyst K 04.80 : Apical and lateral cyst K 04.81 : Residual cyst K 04.82 : Inflammatory paradental cyst WHO CLASSIFICATION Chandra SB,Gopikrishna V;Grossman’s Endodontic Practice 12 Ed; 2010;Wolters Kluver 65
  66. 66. PERIAPICAL PATHOLOGY Symptomatic apical periodontitis (acute apical periodontitis): a painful response to biting and percussion. It may or may not be associated with an apical radiolucent area. Asymptomatic apical periodontitis (chronic apical periodontitis):It appears as an apical radiolucent area, and does not produce clinical symptoms Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 66
  67. 67. ACUTE Vs CHRONIC gradual onset, little or no discomfort, and the intermittent discharge of pus through an associated sinus tract. Acute apical periodontitis rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation, and eventual swelling of associated tissues Chronic apical (periapical) periodontitis Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 67
  68. 68. An acute apical abscess may result when large numbers of bacteria get past the apex and elicit a severe inflammatory response. .This response is acute, the predominant cell being the polymorphonuclear leukocyte. With the release of PMN lysosomal enzymes into the tissue space and the concomitant tissue degradation, an abscess forms An abscess is defined as a localized collection of pus which, microscopically, is composed of dead cells, debris, PMNs, and macrophages. ACUTE APICAL ABSCESS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 68
  69. 69. CLINICAL MANIFESTATION varying degrees of swelling occur, with pain. The patient complains of a feeling that the tooth is elevated out the socket. Elevated temperature and malaise may follow. The body respo to this insult by trying to isolate the abscess and/or establish drainage either intraorally or extraorally. If drainage is not effect the abscess may spread into fascial planes or spaces of the he and neck. PHONIX ABSCESS If a periapical radiolucency is present and an acute inflammato response is superimposed on this preexisting chronic lesion it i termed a phoenix abscess. ACUTE APICAL ABSCESS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 69
  70. 70. • Acute osteomyelitis can arise directly from an endodontic infection. • Live bacteria are past the apex and now are multiplying in the marrow spaces and soft tissue of the bone. • Osteomyelitis may be a serious progression of periapical infection that results in diffuse spread through the medullary spaces, ultimately leading to necrosis of bone. • Acute osteomyelitis may be localized or spread throughout large areas of bone ACUTE OSTEOMYELITIS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 70
  71. 71. CLINICAL MANIFESTATION • The patient usually has severe pain, an elevated temperature, and palpable lymph nodes. • Although the teeth are loose and sore in the early stages, there may be no swelling, and radiographic changes are difficult to detect • There may or may not be pus formation • If untreated, the acute form may progress to chronic disease. • Clinically, chronic suppurative osteomyelitis is the same as acute except the symptoms are milder and radiographically diffuse bone resorption is evident. ACUTE OSTEOMYELITIS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 71
  72. 72. TREATMENT Hyperbaric oxygen Endodontic therapy or extraction of the carious tooth More surgical treatment may be required Aggressive antibiotic therapy to nail the causative bacteria ACUTE OSTEOMYELITIS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 72
  73. 73. • An apical lesion that has established drainage through a sinus tract is termed suppurative inflammation CLINICAL MANIFESTATION • The patient may complain of a "gum boil" or a badtaste in the mouth. • Pus may be expressed through the opening by gentle pressure. • A radiograph should be exposed with a gutta-percha probe inserted into the tract to determine the cause of the lesion. SUPPURATIVE APICAL PERIODONTITIS Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 73
  74. 74. • A foreign body response may occur to many types of substances. • The reaction can be acute and/or chronic • These lesions may or may not be symptomatic. • The cause is now beyond the apex, so surgery may be necessary to remove the foreign material and effect healing FOREIGN BODY REACTION Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 74
  75. 75. • The inflammatory response depends on the quality, duration, and virulence of the irritant. • A very low-grade, subclinical response may lead to an increase in the bone density rather than resorption and radiolucency. • This lesion may be clinically asymptomatic and radiographically can demonstrate increased trabeculation and opacity • If it is associated with a necrotic or diseased pulp endodontic therapy may lead to healing Osteosclerosis or condensing osteitis Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 75
  76. 76. • This is a chronic inflammatory lesion that has epithelium lining the lumen, but the lumen has a direct communication with the root canal system. • It is not a true cyst, because a true cyst is a three-dimensional, epithelium-lined cavity with no communication between the lumen and the canal system • The distinction between a bay and a true cyst is important from the standpoint of healing • While bay cyst can be treated with endodontic therapy true cyst requires surgical excision (Vaulderhaug , Bhsskar SN 1971;Mortensen etal 1972) BAY CYST Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 76
  77. 77. Antibioma is a sterile, chronic abscess formed because of incomplete treatment of an infection by using antibiotics without incision and drainage. It may present with pain, swelling, and tenderness or with mass effect in the form of neuralgic pain. ANTIBIOMA 77
  78. 78. THE STORY 78
  79. 79. CASE HISTORY CHIEF COMPLAINT HISTORY OF PRESENT ILLNESS MEDICAL HISTORY DENTAL HISTORY DRUG HISTORY 79
  80. 80. PAIN MODE OF ONSET : Spontaneous or provoked FREQUENCY & DURATION : continuous or intermittent QUALITY OF PAIN : Dull aching : pain of bony origin Throbbing or pulsing : Pain of vascular origin Sharp stabbing recurrent : pathology of nerve root complex POSTURAL CHANGES : Pain increases on bending or lying down indicates pulpal pain 80
  81. 81. TYPE OF PAIN Momentary pain Persistent pain Spontaneous pain Provoked pain 81
  82. 82. EXTRAORAL EXAMINATION Facial symmetry Lymph nodes TMJ 82
  83. 83. INTRAORAL EXAMINATION SOFT TISSUSE EXAMINATION Swelling Discoloration Sinus formation Gingival inflammation 83
  84. 84. VISUAL EXAMINATION Mobility in primary tooth may be physiological or pathological WYMAN’S INDEX : 0:horizontal <0.2mm 1 : Horizontal 0.2-1mm 2 : Horizontal 1-2mm 3 : Horizontal >2mm & Vertical 84
  85. 85. PERCUSSION : can be checked by applying finger pressure on the tooth or tapping with tip end of handle of the mirror ; if pain then periodontal ligament is inflamed. Lateral percussion is done to check for lateral periodontitis or periodontitis of gingival origin Apical / vertical percussion is done to check for apical periodontitis PALPATION : simple test done with finger tips using light pressure to examine tissue consistency & pain response EXPOSURE SITE : Light red blood that can be arrested easily is associated with inflamed coronal pulp of primary teeth. Deep red blood indicates that inflammation has extended into the root canals of primary teeth Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC 85
  86. 86. PULP TESTING Thermal Test : Heat Test / Cold Test No Response Mild – Moderate response that subsides in 1-2 sec Strong Momentary pain that subsides in 1-2 secs Moderate to strong pain for several secs. or longer Cold tests are most likely to give a positive response in the cervical area compared to the occlusal surface 86
  87. 87. ELECTRIC PULP TESTING False positive response : improper isolation, liquefactive necrosis of pulp,apprehensive patient, electrode contacts with metal restoration or gingiva False negative response : recent trauma to tooth,calcification of root canal,immature apex formation,partial necrosis, incomplete circuit formation,Heavy premedications • Isolate the tooth to be tested • Apply electrolyte on the electrode & place it against the dried enamel surface • Retract the patient cheek with free hand to complete the circuit • Apply mild current & increase slowly Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc 87
  88. 88. Jacobson reported that the optimal placement of the probe tip in vitro was the occlusal two-thirds on the labial or buccal surfaces of teeth. Other investigators have reported that the incisal edge was the optimal placement site to achieve the lowest possible threshold for an EPT response. The threshold increased as the probe tip was moved toward the gingival margin. Jacobson JJ. Probe placement during electric pulp-testing procedures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1984;58(2):242–7. 88
  89. 89. • Thermal pulp testing depends on the outward and inward movement of the dentinal fluid, whereas electric pulp testing depends on ionic movement. • Because of their distribution, larger diameter than that of C fibres, their conduction speed and their myelin sheath, A-delta fibres are those stimulated in electric pulp testing. • C fibres do not respond to electric pulp testing. Because of their high threshold, a stronger electric current is needed to stimulate them. • Based on the hydrodynamic effect, outward movement of dentinal fluid caused by the application of cold (contraction of fluid) produces a stronger response in A-delta fibres than inward movement of the fluid caused by the application of heat. • Repeated application of cold will reduce the displacement rate of the fluids inside the dentinal tubules, causing a less painful response from the pulp for a short time, which is why the cold test is sometimes refractory. Some pointers…. Elmeguid AA Yu DC: Dental Pulp Neurophysiology: Part 1. Clinical and Diagnostic Implications;JCDA;2009;75(1):55-59 89
  90. 90. • The A-delta fibres are more affected by the reduction of pulpal blood flow than the C fibres because the A-delta fibres cannot function in case of anoxia. • An uncontrolled heat test can injure the pulp and release mediators that affect the C fibres • A positive percussion test indicates that the inflammation has moved from the pulp to the periodontium, which is rich in proprioceptors, causing this type of localized response Elmeguid AA Yu DC: Dental Pulp Neurophysiology: Part 1. Clinical and Diagnostic Implications;JCDA;2009;75(1):55-59 90
  91. 91. Percussion Testing is most reliable in primary teeth. (C Delta fibres) Thermal sensitivity Testing & Electrical Pulp Testing are NOT very reliable in primary teeth( A Delta fibres ) because of failure of complete development of Rashkow’s nerve plexus 91
  92. 92. RADIOGRAPHIC INTERPRETATION Pathologic bone resorption. The bone destruction is seen in the furcation area of the tooth. The finding of bone resorption is indicative of widespread pulpal necrosis and nonvitality of the associated tooth. Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc 92
  93. 93. Pathologic root resorption. Commonly associated with pathologic bone resorption . Internal/External resorption. It will probably be seen in the root canals and again is evidence of advanced degenerative changes throughout the pulp. Pulp therapy will generally not be successful as the resorptive process is not readily retarded. Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc 93
  94. 94. Calcific changes. Calcified bodies (known as calcific masses or globules) present in the pulp indicate advanced pulpal degeneration with inflammation spread throughout the coronal portion of the pulp. Widened periodontal membrane/ligament. A widened PDL is usually indicative of pulpal pathology. Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker 94
  95. 95. HISTOLOGY Vs RADIOGRAPHY HISTOLOGIC APPEARANCE RADIOGRAPHIC FEATURES Incipient apical periodontitis Bone structural changes Initial inflammation with acute features Bone structural changes Chronic inflammation Bone demineralisation; lesion area defined Granuloma or cyst formation Radioluscent area; peripheral bony rim Lesion with features of exacerbation Bone structural changes peropheral to lesion Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker I 95
  96. 96. PERIAPICAL INDEX SCORING rstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radiographic96
  97. 97. Normal pulp Reversible pulpitis Irreversible pulpitis Asymptoma tic Irreversible pulpitis symptomati c Pulp necrosis signs none Patient history No h/o spontaneous pain No h/o spontaneous pain none Spontanoeus pain No pain to severe pain Cold test Quick mild response to cold which doesn’t linger Quick & sometimes sharp response discomfort does not linger Quick & sometimes sharp response & discomfort does not linger Exagerrated response to cold with linering pain No response Percussion sensitivity negative Negative Negative May be positive No response to exaggerated response Radiographic findings normal normal Caries present; normal pdl or thickened pdl Normal pdl or thickened pdl Normal periapex to large periapical radioluscenc yZero DT, Zandona AF,Macapagal M,Spolnik KJ; Dental caries & pulpal disease ; Dent Clin N Am ;2011; 55;29-46 97
  98. 98. Normal periapex Symptomatic AP Asymptomati c AP Acute apical abscess Chronic apical abscess Patient history none Pain when biting none Extreme pain on biting Usually none vitality wnl Usually no response to vitality No response to vitality No response No response percussion none positive None to slight positive None to slight palpation none May or may not be positive WNL positive None to slight with sinus tract present Radiographic findings normal Widenend PDL space or periapical radiolusceucy Periapical radioluscency Widened PDL space to periapical radioluscecy Periapical radioluscency Zero DT, Zandona AF,Macapagal M,Spolnik KJ; Dental caries & pulpal disease ; Dent Clin N Am ;2011; 55;29-46 98
  99. 99. Anesthetic testing (Grossman 1978) Source of pain may be identified by giving intraligamentary anesthetic when all other tests fail to isolate the tooth in question Test Cavity : (Seltzer & Bender 1975) Every tooth is drilled upto the Dentinoenamel junction using slow speed hand piece without water. If sensitivity present then pulp is vital. Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc 99
  100. 100. WHAT’S NEW…? 100
  101. 101. Photoplethysmography • Passing of light through the tooth & measuring existing wavelength using galvanometer.Vital pulp will show vascular dilatation on warming it which will be recorded as current on the galvanometer. • This is an optical measurement technique that can be used to detect blood volume changes in the microvascular bed of tissue. • The basic form of PPG technology requires only a few opto-electronic components: a light source to illuminate the tissue (e.g., skin or tooth) and a photodetector to measure the small variations in light intensity associated with changes in perfusion in the catchment (study) volume. Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc 101
  102. 102. • It is a method independent of a pulsatile circulation. The presence of arterioles rather than arteries in the pulp and its rigid encapsulation by surrounding dentine and enamel make it difficult to detect a pulse in the pulp space. • This method measures oxygenation changes in the capillary bed rather than in the supply vessels and hence does not depend on a pulsatile blood flow. • Oximetry by spectrophotometer determines the level of oxygen saturation in the pulpal blood supply with a dual-wavelength light source (760 and 850 nm). Dual wavelength spectrometry Tyagi SP, Sinha DJ, Verma R, Singh UP. New vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90 102
  103. 103. • Teeth with vital pulps fluoresced normally but the teeth with necrotic or absent pulps do not fluoresce when exposed to ultraviolet light. • There are differences in characteristics of healthy dentin and decayed dentin fluorescence spectra at excitations of 405 nm and 440 nm UV light • Fluorescence from the pulp are substantially lower than the healthy and decayed dentin fluorescence. FIBREOPTIC FLUORESCENT SPECTROMETRY Tyagi SP, Sinha DJ, Verma R, Singh UP. New vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90 103
  104. 104. • Xeroradiography is an electrostatic process which uses an amorphous selenium photoconductor material, vacuum deposited on an aluminum substrate, to form a plate. • The key functional steps in the process involve the sensitization of the photoconductor plate in the charging station by depositing a uniform positive charge on its surface with a corona-emitting device called scorotron • The generated latent image is developed through an electrophoretic development process using liquid toner. • Soft tissues on xeroradiographic films have well defined outlines that may permit confident evaluation of the soft tissue height and contour. • Xeroradiographs provide greater overall soft tissue detail making possible evaluation of its density, texture, and contents. • It reveals soft tissues calcifications which are not easily discerned in conventional radiographs.This property may be employed in endodontics to visualized early pulpal calcifications. • detailed visualization of lamina dura, bony trabeculae, fine metal nstruments like files, broaches etc, root apices, periodontal ligament spaces Xeroradiography Udoye C,Jafarzadeh H : ,Xeroradiography: Stagnated after a Promising Beginning Historical Review;Eur J Dent 2010;4:95-99) 104
  105. 105. TOOTH TEMPERATURE Hugeyes Probeye Camera : it can record temperature changes as small as 0.1oC.it requires thermal video system & silicon close up lens Here a color image is produced which indicates a relative difference in temperature in both superficial and deep areas. Computer-controlled infrared thermographic imaging is another noninvasive method of recording the surface temperature of the body. The use of Huges Probeye 4300 Thermal Video System (Hughes Aircraft Co., Carlsbad, CA) was reported in 1989 by Pogrel et al.[55] and was found to be sensitive enough to measure temperature differences as low as 0.1°C. Newer, less cumbersome, and easier to use models is now available. Thermography : recording the infrared radiations emitted from the tooth Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc 105
  106. 106. Pulse Oximetry uses red and infrared wavelengths in order to transilluminate a tissue and detects absorbance peaks due to pulsatile circulation and uses this information to calculate the pulse rate and oxygen saturation. Beer- Lambert’s law: the absorption of light by a solute is related to its concentration at a given wavelength. Pulse Oximetry also uses the characteristics of hemoglobin .i.e in the red and infrared range ‘oxy’ hemoglobin absorbs more light in the red range than ‘deoxy’ hemoglobin and vice versa in the infrared range. Oxygen saturation of Pulp.Avg value : (Pulp) 94% PR : 72/min PULSE OXIMETER Tyagi SP, Sinha DJ, Verma R, Singh UP. New vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90. 106
  107. 107. LASER DOPPLER FLOWMETRY • Doppler frequency shift • The fraction of light that is scattered back from the illuminated area is detected & processed to give a signal which is a measure of the blood flow in the dental pulp • The total backscattered light is processed to produce an output signal which is commonly recorded as the concentration and velocity (flux) of cells using an arbitrary term “perfusion units” (PU), (2.5 volts of blood flow = 250 PU). Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc 107
  108. 108. Transillumination (using Fibreoptic light) Incomplete crack in the tooth (greenstick fractures) Pulp vitality in anterior teeth post trauma. UV Light : 1.Some objects possess the unusual feature of being able to emit light of a higher wavelength when illuminated with UV light. That principle is called fluorescence. 2.Foreman reported that teeth with necrotic pulps and teeth with endodontic treatment did not fluoresce when exposed to UV light while teeth with vital pulps fluoresced normally Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc 108
  109. 109. • The device uses a transducer (a crystal containing probe), a coupling agent and software with customized electronic and digital signal processing algorithms. • US waves are generated when an alternating current (3-10 MHz) is applied to the crystal as a consequence of the piezoelectric effect. • When the operator moves the probe in the examination area a change is created on the sector plane, thus producing a real-time three-dimensional image of that particular space. • US has the ability to penetrate hard tissues and in principle can successfully detect discontinuities and pathosis even under existing radio-opaque restorations. • Because the different biological tissues in the body possess different mechanical and acoustic properties, the US waves at the interface between two tissues with different acoustic impedance undergo the phenomena of reflection and refraction. • The echo is the part of the US wave that is reflected back from the tissue interface toward the transducer. USG Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc 109
  110. 110. • When applied to US examination, Color Power Doppler flowmetry allows the presence and direction of the blood flow within the tissue of interest to be observed. • The intensity of the Doppler signal is represented by changes in real time on a graph (Doppler) and is also shown in the form of color spots on the gray scale image (color). • Positive Doppler shifts are caused by the blood moving toward the transducer and are represented in red, whereas negative Doppler shifts are caused by blood moving in the opposite direction and are represented in blue. ULTRASOUND DOPPLER 110
  111. 111. MRI Best resolution of tissue of low inherent contrast No ionizing radiations involved Direct multiplanar image is possible without reorienting the patient Disadvantages: 1. Potential hazard due to presence of large ferromagnetic metals in the vicinity 2. Long imaging time The nature of periapical lesions could be determined as well as the presence, absence and/or thickening of the cortical bone. Goto et al. (2007) No artefacts (Eggars et al. 2005) Cotti & Campisi (2004) Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc 111
  112. 112. Cholesteric liquid crystals Cholesteric crystals are a type of ‘liquid’ crystal, i.e. ordered fluids, with a helical structure ordered along the long axis known as chiral- nematic liquid crystals. Due to their fluidity these are easily influenced by temperature or pressure. The pitch of the very structure of the crystal varies when the pressure or temperature are altered thus changing their color heated i.e. they are thermochromic. When applied to the tooth surface, the crystals undergo color changes that were compared with adjacent or contralateral-teeth Inferences : Vital Non Vital blue green Red Red Green Yellow Green Yellow red Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc 112
  113. 113. • 3D volume of data is acquired in the course of a single sweep of the scanner, using a simple, direct relationship between sensor and source, which rotate synchronously through 180–360 around the patient’s head. • The X-ray beam is cone-shaped (hence the name of the technique) and captures a cylindrical or spherical volume of data, described as the field of view • The size of the field of view (FOV) is variable, large volume CBCT scanners (for example, i-CAT; Imaging Sciences International, Hatfield, PA, USA and NewTom 3G, QR, Verona, Italy) being capable of capturing the entire maxillofacial skeleton. • Some CBCT scanners also allow the height of the cylindrical field of view to be adjusted to capture only the maxilla or mandible CBCT Tyagi SP, Sinha DJ, Verma R, Singh UP. New vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90 113
  114. 114. 114
  115. 115. Based on tomosynthesis (Webber & Messura 1999). A series of 8–10 radiographic images are exposed atdifferent projection geometries using a programmable imaging unit, with specialized software to reconstruct a three-dimensional data set which may be viewed slice by slice Diagnostic accuracy of TACT was superior to conventional two- dimensional radiography for the detection of vertical root fractures(Nair etal 2001,2003) Complex nature of the adjacent anatomy around posterior maxillary molar teeth limits the use of TACT(Barton et l 2003) The resolution is reported to be comparable with 2D radiographs (Nair & Nair 2007). TACT is more diagnostically informative and had more impact on potential treatment options than conventional radiographs Cotti & Campisi 2004, Nair & Nair 2007, Patel et al. 2007). TACT Tyagi SP, Sinha DJ, Verma R, Singh UP. New vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90 115
  116. 116. • Given radiographs taken in precisely the same position and with the same beam geometry and exposure parameters, images can be subtracted to show changes over time. • Major drawbacks include difficulties experienced in practice in achieving images with reproducible projection geometry over time. DIGITAL SUBTRACTION RADIOGRAPHY Tyagi SP, Sinha DJ, Verma R, Singh UP. New vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90 116
  117. 117. In a nutshell… 117
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