1、Endodontic,Classification, Diagnosis and Clinical manifestations of Endodontic Disease,Guanghua School Stomatology Sun Yat-sen University Zeng Jinfeng,Dental PulpSelzer and Bender （the 2nd /3th edition）,Pathways of the Pulp Stephen Cohen （the 8th / 9th / 10th edition）,Endodontics Ingle （the 6th /new
2、 edition）,Reference,Endodontics,Chapter1 Modern endodontic therapy Chapter2 Histology and physiology of the dental pulp Chapter6 Endodontic diagnostic procedures Chapter9 Preparation for endodontic treatment Chapter10 Endodontic cavity preparation ,Pathways of the Pulp,Part one: The art of endodonti
3、csDiagnostic proceduresCleaning and shaping the root canal systemOturation of the cleaned and shaped root canal system Part two: The science of endodonticsInstruments,materials and devices Part three: Related clinical topicsEndodontic microsurgerynonsurgical endodontic retreatmentmanagement of pain
4、and anxiety,Dental Pulp,1. History of pulp biology 2. Development of the pulpodentin complex 3. Dentin formation and repair 13. Calcium hydroxide and vital pulp therapy 14. Repair of pulpal injury by dental materials 20. Differential diagnosis of odontalgia 21. The dental pulp in systemic disorders,
5、Disease Process,Endodontics disease,Pulpitis,Microbiological,Periapical Periodontitis,Normal Pulp,Endodontics disease,Vitality(?),Nerves,Blood Vessels,Normal Pulp,Endodontics disease,Sensibility!,Nerves,C-fibers,A-delta fibers,Normal Pulp,Endodontics disease,Dentin-pulp complex,Nerve supply,C-fibers
6、,A-delta fibers,A-fibers are myelinated and conduct rapid and sharp pain sensations,C-fibers are unmyelinated and thinner, and are involved in dull aching pain,Trowbridge 1985 Narhi et al 1982,Normal Pulp,Endodontics disease,Nerve supply,C-fibers,A-delta fibers,A-delta: Sharp Pain Primarily Mechanor
7、eceptors can be localized,C: Dull Pain Mech and Chemo receptors poorly localized,Inflamed Pulp,Endodontics disease,Hyperalgesia 痛觉过敏,Increased pain sensation,Enhanced response to a stimulus that is normally painful,Allodynia 异常性疼痛,Lower pain threshold,Pain induced by stimuli that are not normally pa
8、inful,Pain Taxonomy, 1994,Inflamed Pulp,Endodontics disease,Thermal Allodynia,Normal Physiologic Temperature（37) Ice water to relieve pain from pulpitis,Mechanical Allodynia,Normal Systolic Blood Pressure Throbbing Pulpal Pain with heartbeat,PercussionPositive percussion,Narhi, JDR, 1985,Inflamed Pu
9、lp,Endodontics disease,However it is common to find cases with histologic evidence of severe inflammatory responses, including partial necrosis, but little or no clinical symptoms.,Incidence of painless pulpitis that leads to pulp necrosis and chronic periradicular periodontitis is about 40% to 60%
10、of pulpitis cases.,Mitchell, Oral Surg Oral Med Oral Pathol. 1960 Seltzer S, Bender IB, Oral Surg Oral Med Oral Pathol. 1963 Michaelson, Int Endod J. 2002,Inflamed Pulp,Endodontics disease,Little correlation between clinical symptoms and histopathological state of the pulp.,Seltzer et al 1963:,Infla
11、med Pulp,Endodontics disease,Only significant correlation between clinical signs and pulpal pathology was with a history of spontaneous pain,Seltzer et al 1963:,Spontaneous Pain,Endodontics disease,Histologic diagnosis Clinical diagnosis,Classification,Histology diagnosis,Endodontics disease,Histolo
12、gic examination Removing the pulp Impossible and unrealisticLack of correlation between clinical signs and symptoms and the actual histologic status of the pulp,Histology diagnosis,Endodontics disease,Pulp hyperemia Acute pulpitis Chronic pulpitis Pulp necrosis/gangrene Pulp degeneration/calcificati
13、on Internal tooth resorption,Histology diagnosis,Endodontics disease,Pulp hyperemia,Acute pulpitis,Chronic pulpitis,Histology diagnosis,Endodontics disease,Pulp calcification,Internal tooth resorption,Histology diagnosis,Endodontics disease,Clinical diagnosis,Endodontics disease,Based on the patient
14、s symptoms and the results of clinical tests Describe the extent of pulpal disease Help the clinicians to select the correct treatment methods,Clinical classification,Endodontics disease,Reversible pulpitis Irreversible pulpitis Pulp necrosis Pulp calcification Internal resorption,Pulpal Diagnosis,E
15、ndodontics disease,AAE (American Association of Endodontists) Normal Reversible pulpitis Symptomatic Irreversible pulpitis Asymptomatic Irreversible pulpitis Pulp Necrosis Previously Treated Previously Initiated Therapy,www.aae.org,Reversible pulpitis (Hyperemia),Endodontics disease,not a disease, b
16、ut a symptom pulp state: vasodilator/hyperemia asymptomatic thermal stimuli (usually cold)quick, sharp, hypersensitive responsesubsides as soon as the stimulus removed,Dental hypersensitiveness,Reversible pulpitis (Hyperemia),Endodontics disease,Irritants caries periodontal scaling root planning mic
17、roleakage unbased restorations,Endodontics disease,Prognosis irritant removed further appropriately treatedpulp will revert to an asymptomaticuninflamed state irritant remainssymptoms persist /more widespread irreversible pulpitis,Reversible pulpitis (Hyperemia),Endodontics disease,Distinguished fro
18、m irreversible pulpitiscomplaint of spontaneous pain reversible pulpitisNo! irreversible pulpitisYes!,Reversible pulpitis (Hyperemia),Endodontics disease,Distinguished from irreversible pulpitisThermal test reversible pulpitismomentary, painful response subsides ASA the stimulus removed irreversible
19、 pulpitispainful, linger after the stimulus removed,Reversible pulpitis (Hyperemia),Irreversible pulpitis,Endodontics disease,Acute pulpitis Chronic pulpitisChronic pulpitis with a closed pulp chamberChronic ulcered pulpitisHyperplastic pulpitisResidual pulpitisRetrograde pulpitis,Irreversible pulpi
20、tis- Acute pulpitis,Endodontics disease,The patient is experiencing one of the mostexcruciating acute pains known to humanity,comparable to otic abscess, renal colic, and childbirth. If every dentist personally experienced thepain of advanced acute pulpalgia, he would be a more sympathetic practitio
21、ner for the experience.,Irreversible pulpitis- Acute pulpitis,Endodontics disease,This patient is in exquisite agony and sometimes becomes hysterical from the pain. The patient is often crying and virtually unmanageable.,Irreversible pulpitis- Acute pulpitis,Endodontics disease,One patient, who had
22、to drive 40 miles to a dentist, reported that he could stand the pain no longer, so he stopped the car, took out a pair of pliers, and pulled his own tooth.Patients have confessed contemplating suicide to escape the pain.“牙痛不是病，痛起来要人命”,Acute pulpitis-Characteristics,Endodontics disease,spontaneous/u
23、nprovokedintermittent/continuous paroxysms postural change - a fitful night temperature changepain that lingers after the thermal stimulus is removed nonlocalization,Histology & physiology of pulp & periapex,Clinical Aspects of Vascular Supply,Patients with pulpitis report an inability to sleep at n
24、ight because they are disturbed by throbbing tooth pain. The lack of distractions normally present during the day When these patients lie down, their pulpal blood flow increases due to the cardiovascular postural responses. This may increase their already elevated pulpal tissue pressure, which is th
25、en sufficient to activate sensitized pulpal nociceptors（伤害感受器） and initiate spontaneous pulpal pain.Thus the “throbbing” sensation of a toothache is due to the pulsation in the pulp that follows systole（心脏收缩）, causing intermittent increases in pulpal tissue pressure.,Acute pulpitis- Characteristics,
26、Endodontics disease,Referred pain A. The maxillary canine may refer to the maxillary first or second premolars and/or the first or second molars, as well as to the mandibular first or second premolars.,Endodontics disease,Referred pain B. Maxillary premolars may refer pain to the mandibular premolar
27、s. The reverse is also true.,Acute pulpitis- Characteristics,Endodontics disease,Referred pain C. Mandibular incisors, canine, and first premolar may refer pain intothe mental area.,Acute pulpitis- Characteristics,Endodontics disease,Referred pain D. Mandibular second premolar may refer pain into th
28、e mental and midramus area(中支).,Acute pulpitis- Characteristics,Endodontics disease,Referred pain E. Mandibular first or second premolars may also refer pain into maxillary molars.,Acute pulpitis- Characteristics,Endodontics disease,Referred pain F. Mandibular molars may refer pain forward to the ma
29、ndibular premolars.,Acute pulpitis- Characteristics,Endodontics disease,Acute pulpitis- Referred pain,Endodontics disease,Acute pulpitis- Examination,Oral/visual examination deep caries, deep wedge-shaped defect, extensive restorations, severe abrasion, crack, deep periodontal pocket, detection: sev
30、ere pain percussion: (-)/(+),Deep caries,Secondary caries,Wedge-shaped defect,Tooth defect,Attition,Deep periodontal pocket,Vertical root fracture,Cracked tooth,Endodontics disease,Acute pulpitis- Examination,Thermal tests (the conclusive test) Heat test (gutta-percha bar) elicit prolonged episodes
31、of pain linger after the thermal stimulus is removed cold water can relieve this pain,Endodontics disease,Acute pulpitis- Examination,Radiograph examination help to provide some information of the tooth: deep caries, extensive restorations pins, evidence of previous pulp capping, a thickened periodo
32、ntal membrane spaceat the apex, the inflammation spreads out of the pulp,Endodontics disease,Local anesthesiaDiagnosisPain relief Local anesthesia gives blessed relief, and the dentist has, from that moment, made a friend for life. The friendship will be more lasting if the tooth is saved by endodon
33、tic therapy rather than extracted.,Acute pulpitis- Examination,Endodontics disease,Acute pulpitis- Distinguish,Trigeminal paintrigger point Papillary gingival inflammationnormal teeth Acute maxillary antrum inflammationnormal teeth, headache, snuffle,Endodontics disease,Acute pulpitis- Distinguish,D
34、istinguished from trigeminal pain trigger point rarely happens in the night painnot related to the thermal stimuli,Endodontics disease,Acute pulpitis- Distinguish,Distinguished from papillary gingival inflammation spontaneous pain, especially swelling pain sensitive to the themal test localization p
35、apillary gingival hyperemia, swelling, haphalgesia（触痛） history of food impact not related to other hard tissue diseases,Endodontics disease,Acute pulpitis- Distinguish,Distinguished from acute maxillary sinusitis continuous swelling pain not related to other hard tissue diseases maxillary sinus wall
36、pressing pain Symptoms: headache, stuffy nose, pus snot,Endodontics disease,Irreversible pulpitis,Chronic pulpitis,Endodontics disease,Irreversible pulpitis- Chronic pulpitis,Complains/“grumble” discomfortable mild pain vague pain weeks, months, or years easy control with analgesic tablets,Endodonti
37、cs disease,Irreversible pulpitis- Chronic pulpitis,Classifacation Chronic pulpitis with a closed pulp chamber Chronic ulcered pulpitis Hyperplastic pulpitisResidual pulpitis Retrograde pulpitis,Endodontics disease,Irreversible pulpitis-Chronic pulpitis,Chronic pulpitis with a closed pulp chamber dee
38、p caries/recurrent cariesextensive restorations (near the chamber) detection: bluntness/inaction percussion: (+) / (+-) pulp test: no-reaction/slow-reaction radiograph: “thicken” periodontal membrane,deep caries,decay is deep into the tooth,Endodontics disease,Irreversible pulpitis-Chronic pulpitis,
39、Endodontics disease,Irreversible pulpitis-Chronic pulpitis,Chronic ulcered pulpitis typical complainpainful when compressed by food packed into the cavity pulp chamber opened and ulcered pulp detection: pain and bleeding percussion: (-) /(+-),Chronic ulcered pulpitis,Endodontics disease,Irreversible
40、 pulpitis-Chronic pulpitis,Hyperplastic pulpitis typical complainbleeding when chewing pulp polyp(牙髓息肉) tartar in the same side in young people distinguish from the other polyp,Pulp polyp,Periodontal membrane polyp,Polyp gum,Endodontics disease,Irreversible pulpitis-Chronic pulpitis,Residual pulpiti
41、s treated tooth (uncomfortable treatment)missing canal, residual pulp, percussion: (+) /(+-) pulp test(strong): slow-reaction radiograph: “thicken” periodontal membrane final decision: painful when canal detection,12,14,Endodontics disease,Irreversible pulpitis-Chronic pulpitis,Residual pulpitis,End
42、odontics disease,Irreversible pulpitis-Chronic pulpitis,Residual pulpitis missing canal （MB2）,Sagittal CT films,Coronal CT films,Endodontics disease,Irreversible pulpitis-Chronic pulpitis,Retrograde pulpitis pulpitis and periodontitis deep periodontal pocket percussion: (+)/(+) pulp test: difference
43、 radiograph：radiolucency around the root and furcation,Endodontics disease,Irreversible pulpitis-Chronic pulpitis,Retrograde pulpitis,Endodontics disease,Pulp necrosis,coronal discoloration with no true symptoms an accident of years ago percussion: (-)/(+-) pulp test: no reaction radiogralph: normal
44、 distinguish from chronic periapical periodontitis,Endodontics disease,Pulp necrosis,coronal discoloration,Endodontics disease,Pulp calcification,No true symptoms Radiograph: pulp chamber calcified locally or dispersedly an accident of years ago/calcium hydroxide treated,Endodontics disease,Pulp cal
45、cification,髓石,Endodontics disease,Internal Resorption,“pink tooth” visual examination radiographic examination thermal tests and electric pulp test (normal / bluntness),Endodontics disease,Internal Resorption,preoperative postoperative,Endodontics disease,Internal Resorption,36 distal root internal
46、resorption,Nonodontogenic Toothache,Guanghua School Stomatology Sun Yat-sen University Sui Mai,Classification,Nonodontogenic toothache,musculoskeletal & somatic pain(骨骼肌&身体痛） toothache referred from a distant organic source neuropathic pain （神经性疼痛） psychogenic toothache（心理性牙痛）,musculoskeletal & soma
47、tic pain,Nonodontogenic toothache,myofascial pain（肌筋膜痛）most commontrigger pointa diffuse, constant, dull, aching sensationpain when chewingpain of sinus and/or nasal mucosal originsalivary gland pain,toothache referred from a distant organic source,Nonodontogenic toothache,cardiac and thoracic struc
48、tures,felt in the lower left jaw pain can be spontaneous and diffuse with a cyclic pattern that fluctuates in intensity from mild to severe the pain can also be intermittent and the patient may be completely asymptomatic at times diagnosis of cardiac pain, along with immediate referral, is mandatory
49、 to avoid impending myocardial infarction（心肌梗塞）,Angina Pectoris（心绞痛）,toothache referred from a distant organic source,Nonodontogenic toothache,intracranial （颅内）structuresthroat and neck structurescraniofacial（颅面） structures,neuropathic pain,Nonodontogenic toothache,neuralgia（神经痛）trigeminal neuralgiaan intense, sharp shooting pain most often unilateraltrigger zonesneuroma（神经瘤）neuritis（神经炎）neuropathy（神经病）also have been called atypical facial pain,neuropathic pain,Nonodontogenic toothache,Postherpetic neuralgia, PHN,
