DOM 8250 Hard Tissue Diseases & Abnormalities - Dental Caries 2024 PDF

Diagnosis of Hard Tissue Diseases and Abnormalities DOM 8250 September 23, 2024 Shin-Mey R. Y. Geist, DDS, MS, FDS RCSEd Diplomate, American Board of Oral Medicine Associate Professor, University of Detroit Mercy School of Dentis...

Diagnosis of Hard Tissue Diseases and Abnormalities DOM 8250 September 23, 2024 Shin-Mey R. Y. Geist, DDS, MS, FDS RCSEd Diplomate, American Board of Oral Medicine Associate Professor, University of Detroit Mercy School of Dentistry  Objectives Learners will be able to demonstrate : Detection and diagnosis of hard tissue diseases or abnormalities based on prevalence and clinical S & S – Clinical detection and diagnosis of carious lesions and sequelae – Radiographic detection and diagnosis of carious lesions and sequelae – Other imaging techniques in caries detection and others – Detection and diagnosis of other hard tissue abnormalities. Differential diagnoses of dental caries from other dental abnormities (dental fluorosis, erosion, attrition, fracture, abfraction, cracked tooth syndrome, and others) Link the caries or other hard tissue abnormality to systemic health conditions and/or their treatment.  Copyright protected This slide set contains part of MedEdPORTAL publication “Dental Decay and Sequelae in Patients with Diabetes Mellitus”. Those slide contents cannot be republished without MedEdPORTAL’s permission MedEdPORTAL is a global teaching resource center of AAMC (Association of American Medical Colleges) Geist & Geist 1. Diagnosis of Dental Caries and Sequelae (Dental Decay, Carious Lesions and their Complications) “Management of dental caries demands early detection of carious lesions to identify patients who require intensive preventive intervention. It is not to justify premature restorative intervention”. Zandona, JADA 2006 Therefore, it is essential to link patient’s systemic health status for  Biographic. Oral diagnostic process Demographic information General appraisal Chief Complaint Initial history or Physical examination CC health history Vital signs History of the Present illness HPI Extraoral exam Nearly 90% of the diagnoses can be General health history established accurately Intraoral exam Medication history Personal history Diagnosis Supplementary exam Social history Depending on the nature of the disease, examiner’s knowledge and Emotional history experience, diagnosis can be About 10% of the established at different stage of Behavioral history diagnoses examination Oral health history Radiology exams Medical or Specialized exam. Laboratory exams dental consultation Biopsies  Where are we in the diagnostic process for the diagnosis of hard tissue diseases and abnormalities? Health history, physical examination, and specialized exams – Caries and its sequelae are the most common hard tissue diseases in dentistry – Need to differentiate caries and its sequelae from other hard tissue diseases or abnormalities, e.g. dental fluorosis, erosion, attrition, fracture, tooth splitting, and others. – Often use specialized examination methods (radiographic examination)  Symptoms and Signs of Dental Caries What are patient’s CC and HPI? What does it look like? Is there any pattern? (characteristics: smooth surface vs pit and fissure lesions) What are the contributing factors? What is the complete diagnosis for each lesion? What is the comprehensive diagnostic list for a dental patient regarding his/her dental caries? (Whole Person Healthcare) What are the characteristics of this patient’s caries lesions? S&S? Contributing factor(s)? Psychological issue? Behavioral issue? Medication? Hyposalivation? What are the characteristics of this patient’s caries lesions? S&S? Contributing factor(s)? Psychological issue? Behavioral issue? Medication? Hyposalivation?  What are the characteristics of this patient’s caries lesions? S&S? Contributing factor(s)? Psychological issue? Behavioral issue? Medication? Hyposalivation? Is Meth mouth Characteristic or Pathognomonic? Psychological issue? Behavioral issue? Neglect? Substance abuse? What are the characteristics of this patient’s caries lesions? S&S? Contributing factors? Psychological issue? Behavioral issue? Medication? Hyposalivation?  Criteria for diagnosis of dental decay and its sequelae Clinical findings Radiographic findings Correlation between history, symptoms, clinical findings, radiographic findings, and patient’s systemic health status. Establish complete diagnosis for a decayed tooth and comprehensive diagnosis for a patient. Prepare to use a software that will match diagnosis to a ICD-10 CM disease name and code.  How to establish dental caries and its sequelae diagnoses? Matching S & S to a specific diagnosis (name or term and code) to record, report, and to support a treatment procedure. What diagnostic term does it match and should be entered in the electronic health record (EHR)? Always ask: Is it a complete diagnosis? How does is it fit in a comprehensive diagnostic list for the patient?  Symptoms and Signs of Dental caries Symptoms: Patient’s current complaints or history of complaints (CC and HPI) Signs: What has been detected – Clinical-visual, tactile sensation, thermal test, and others – Radiographic: Intraoral or CBCT – Other diagnostic imaging, e.g., optical coherence tomography (OCT) Apply principles of oral diagnosis process for carious lesions (dental caries) and its sequelae diagnosisInspection with good lighting, clean and dry History tooth surfaces Examination Symptoms Signs (current or in the past) Supplementary exam with Sensitivity to hot tactile sensation or cold or other diagnostic tools; Toothache with e.g., cold test hot or cold Spontaneous Specialized exam pain that is with aggravated by Diagnosis adequate cold drink, cold Intraoral radiographic images food, or chewing or other imaging techniques  Symptoms of Dental Caries Caries limited in enamel – No symptom caries penetrating into dentin – Sensitive to sweets; cold or hot stimulus – Pain on sweet, cold, or hot stimulus – History of all the above, but no symptoms at time of the dental exam but they can be reproduced. caries penetrating into pulp – Spontaneous pain that is aggravated by cold  Signs of dental caries Color and/or texture change Lost of tooth structure: holes Supplementary exam findings – Thermal test – tactile sensation with explorer Specialized exam – Imaging exam  Traditional carious diagnostic tools (methods) for signs of caries Inspection exam: visual examination Supplementary exam: tactile sensation with explorer Radiographic exam Traditional caries diagnosis is very subjective, the end result has low sensitivity and high specificity, meaning a large number of lesions may be missed. Clinicians should minimize subjectivity as much as possible by following the criteria guidelines to improve the early detection of carious lesions  Inspection signs Color and/or texture change of tooth surface – Correlate color changes to dynamic caries process (capture the whole continuum of the caries process for all surfaces of teeth, including caries adjacent to restorations) – Recognize the limitations of each clinical diagnostic tool (method) for carious lesion detection including color change.  Inspection with or without tactile sensation There is no need to apply too much pressure on an explorer because studies have found that this does not increase the accuracy of caries detection. The use of gentle pressure, defined by the force just required to blanch a fingernail without causing any pain or damage, is recommended. Hamilton JC , 2005 Is it still subjective?  Detection by color change and with or without tactile sensation What about proximal surfaces? Important: Tooth surface must This is NOT a fracture be clean and dry.  Any other diagnostic tools available for carious signs? Yes Quantitative laser or light fluorescence (QLF) Electrical conductance measurements (ECM) Infrared (IR) laser fluorescence Digital imaging fiber-optic trans- illumination (DIFOTI) Two dimensional radiographic imaging Optical coherence tomography (OTC) CBCT can be helpful to differentiate between tooth split and caries.  Fluorescence The reason that fluorescence can be used for caries detection: The difference in fluorescence observed between sound and demineralized enamel is greater when the enamel is illuminated by light in the blue-green range (488 nanometers is ideal). Quantitative laser or Digital imaging fiber- White light light fluorescence by optic transillumination using an arc lamp with a 290 to 450 nm wavelength  Optical Coherence Tomography (OCT) Uses light to capture micrometer- resolution, three-dimensional images Great potential for early caries detection Radiographic detection of carious lesions also called radiographic finding of dental caries This part was addressed in a prerequisite course (DS1 winter term), please review it. Finding does not equal diagnosis  Conclusion: No single caries detection method is reliable for all surfaces under all circumstances “Not all methods can detect early lesions accurately, and false positive and false negative results may occur. There also is a strong operator influence on the performance of the methods, with different operators obtaining different results.” Carious lesion detection at the Detroit Mercy Dental School We still rely mostly on visual examination, with or without tactile sensation, aided by radiography for caries detection.  Diagnostic Terminology Use ICD-10-CM disease names and codes Be aware axium contain some SNODENT disease names and codes These disease terms are based on S&S and have specific criteria  International Classification of Diseases (ICD-10 and ICD- 10 CM in the U.S.) Chapter XI Diseases of the digestive system (K00-K93) Diseases of oral cavity, salivary glands and jaws (K00-K14) ADA defines what CDT mean and claims ADA is the official and definitive source for CDT  to enamel White spot lesions [initial caries] K02.62 Dental caries on smooth surface penetrating into dentin K02.63 Dental caries on smooth surface Enamel color penetrating change: chalkyinto pulp white or light brown Enamel texture change (consistency): soft, indicating demineralization. – The discolored area has no signs of cavitation after a visual or a gentle tactile examination – The lesion is located in areas where dental plaque may accumulate (close to the gingival margin) – The surface of the area is matted (not Caries limited to glossy) when the surface is cleaned and enamel dried It is still soft after plaque removal. DO NOT poke it with tip of explorer Dx: Tooth #11, labial cervical smooth surface caries limited to enamel. K02.61  Caries on pit and fissure surface (occlusal and buccal or lingual pits) K02.51 –limited to enamel K02.52-penetrating into dentin K02.53-penetrating into pulp Color change (can be a spectrum of dental decay) – Enamel caries-limited to the enamel layer-How can we tell? S&S – Dental caries extending into dentin-- have signs of undermined enamel that appear as an opacity or discoloration inside – Dental caries exposure of pulp-How can we tell? S&S Caries penetrating into dentin, even into pulp  Caries lesion on any cervical (gingival) or other smooth surface area-Depth Color change (chalky white or brown) Visual breakdown in the tooth surface (i.e., hole) Tactile sensation- the area has soft walls or floor. Dx: Labial cervical caries or labial cervical cavities limited to enamel? Penetrating into dentin? Penetrating to the pulp? All based on S & S  Carious lesion of pit and fissure surface and buccal or lingual pits Enamel: Light or dark brown discoloration at the base of the pit or fissure with or without white demineralization at the sides of the pit or fissure that could be detected visually after cleaning and drying the teeth. No breakdown in enamel (no cavity) but the area is soft upon gentle exploring. Active enamel dental caries?  Carious lesion of pit and fissure surface in occlusal areas and buccal or lingual pits Dental caries penetrating into dentin has signs of undermined enamel that appear as opacity or discoloration underneath the surface. ---A Extensive cavitated dental caries penetrating into dentin--B A Caries B penetrating Dental caries into pulp? penetrating into dentin or even deeper Dx: Tooth #14: occlusal pit decay, penetrating into dentin. Caries penetrating into pulp? Pulpal diagnosis? Apical diagnosis? Dx: Tooth #3: MO dental caries penetrating into dentin. Caries penetrating into pulp? Pulpal diagnosis? Apical diagnosis?  Caries in dentin and beyond Clinical finding : Tooth #4 MO cavity. How extensive? Need S&S including radiograph. We need the complete diagnosis of this tooth, not just caries of dentin or MO cavity. Complete diagnosis: Tooth #4 MO cavity penetrating into pulp, pulpal necrosis, and chronic apical periodontitis. Decayed to the root. Is that all? ICD-10-CM term & code?  Caries of cementum (also called dental root caries K02.7) Root caries or caries of cementum is different from decayed to the root. It is also different from arrested decay, K02.3  Arrested carious lesions White spots can be lesions that have self- arrested as part of the natural process of the disease or have arrested owing to a change in the local environment. These lesions can be considered scars from disease activity occurring years or even decades earlier. Arrested lesions are more resistant to subsequent cariogenic challenges than sound enamel and, thus, should not receive restorative treatment unless the patient has esthetic concerns. Arrested carious lesions can also be brown but they are hard. Apply principles of oral diagnosis process for carious lesions (dental caries) and sequelae Inspection with good lighting, clean and dry History tooth surface Examination Symptoms Signs (current or in the past) Supplementary exam with History of tactile sensation Sensitivity to hot or other diagnostic tools; or cold e.g., cold test Toothache with hot or cold Specialized exam Spontaneous with pain that is Diagnosis adequate aggravated by radiographic images cold drink, cold or food, or chewing other imaging techniques Virtual Clinic Case Study #2  Caries limited to enamel Caries penetrating into dentin Caries penetrating into pulp pulpitis Acute apical Chronic apical periodontitis periodontitis ICD-10-CM Acute Chronic ICD-10-CM Periapical abscess apical apical Periapical abscess without sinus abscess abscess with sinus Dentoalveolar abscess Osteomylitis Abscess in fascial spaces  Dental caries: a disease process with the products of dental decay and sequelae Dental Caries into enamel caries Symptoms: none starts at Signs: softened enamel the tooth surface or cavity surface, Caries into dentin penetrating Symptoms: through sensitive to sweet and/or the lifeless cold (dentin enamel hypersensitivity) layer into Signs: chalky or grey tooth deeper discoloration, living tooth cavity layers such as dentin Radiographic finding: and pulp radiolucencies in crown Geist & Geist  Dental Decay at Various Depths on radiographs #13 #14 #20 Radiographically Caries in enamel on distal surface of tooth #13 Caries in dentin layer on mesial surface of tooth #14 Caries close to the pulp on distal surface of tooth #20  Dental caries: a disease process with the products of dental decay and sequelae Decay near or into the pulp horn or Pulpitis pulp chamber Various causes symptoms and inflammation of signs with pain as dental pulp tissue a major complaint (pulpitis) The most common Based on the cause of pulpitis is symptoms and dental caries signs, pulpitis can be classified into Trauma, heat, groups with some restorative different materials and outcomes others can also cause pulpitis Geist & Geist Pulpitis Caries (decay) extends from enamel into dentin and approaches or extends into the pulp horn or pulp chamber Geist & Geist  Pulpitis This is a section of an extracted tooth showing decay underneath the amalgam restoration and close to the pulp horn Pulpitis appears as increased redness (inflammation) at the coronal aspect of the pulp chamber Geist & Geist  ICD-10 CM classification of Pulpitis Based on Symptoms and Signs Reversible pulpitis: pulpalgia with transient toothache on stimulus such as sweet, hot or cold Irreversible pulpitis: pulpalgia with spontaneous toothache aggravated by stimulus that lasts for hours – Most of the time the above mentioned conditions co- exist in one tooth, especially in a multirooted tooth. – Therefore, the patient will have a combination of the above mentioned symptoms. American Association of Endodontics (AAE) further divided it into symptomatic and asymptomatic irreversible pulpitis (NOT in ICD-10 CM) Geist & Geist  Outcomes of Pulpitis Reversible pulpitis: resolved with decay removal and restoration Irreversible pulpitis: proceeds to partial or complete pulpal necrosis, require complete root canal therapy. Geist & Geist  Pulpal Necrosis (necrosis of pulp) A result of irreversible pulpitis It is the most common sequelae of dental decay Complete necrosis: no symptoms Partial necrosis: symptoms depend on the status of non-necrotic pulp Other causes of pulpal necrosis: aseptic necrosis – Ischemic necrosis caused by surgery sever the entering N. – Trauma, other than surgery – Sickle cell anemia (aseptic pulpal necrosis) Geist & Geist  Partial pulpal necrosis Dental decay Inflamed pulp Necrotic pulp Inflamed Abscess periodonta formation l ligament Apical Apical abscess Periodontiti s Geist & Geist  Complete pulpal necrosis (K04.1 Necrosis of pulp) Dental Necrotic decay pulp Necrotic pulp Apical Apical Periodontitis abscess Geist & Geist  Periapical Inflammation: Apical periodontitis Sequela of pulpal necrosis due to decay or other causes A result of : – Reaction to bacteria in root canal and/or – Toxic metabolites of degenerating cells inciting inflammation via cytokines There is good correlation between histology and symptoms; more inflammation causes more severe symptoms, mainly pain. Geist & Geist  Apical periodontitis ICD-10-CM American Association of endodontics (AAE) Acute Symptomatic apical periodontitis apical periodontitis Chronic Asymptomatic apical periodontitis apical periodontitis Geist & Geist Acute Apical Periodontitis (AAP) Manifestation of acute inflammation of periapical tissue Results from pulpitis and pulpal necrosis Can also result from hyperocclusion from dental treatment  S&S of Acute Apical Periodontitis (AAP) Pain on biting or chewing Pain on percussion test Pain can also be spontaneous and aggravated by chewing or percussion test Usually no thermal response (pulp is necrotic) May have thermal response if some pulp is vital (partial necrosis, e.g., multirooted teeth)  Acute Apical Periodontitis (AAP) Histology: Neutrophils and edema, no pus Radiography: Slight widening of periodontal ligament (PDL), or no widening. (Periapical radiolucency present when AAP arises in a chronic lesion) Palliative treatment (gross pulpal debridement or anti-inflammatory agents) Definitive treatment: Endodontic therapy or extraction Geist & Geist Acute Apical Periodontitis Minimal thickening of apical periodontal ligament in a 12-year-old child (what is the difference between tooth #18 and #19? Geist & Geist  Outcome of AAP Resolution after root canal treatment Proceeds to acute apical abscess Proceeds to chronic apical periodontitis Proceeds to chronic apical abscess Proceeds to condensing osteitis (radiographic term for a variant of chronic apical periodontitis) Proceeds to acute or chronic osteomyelitis (M27.2) Geist & Geist Acute Apical Abscess Periapical abscess without sinus K04.7 Usually follows AAP as pus forms Can arise within chronic apical periodontitis Patient complains unable to chew or tooth is extruded Severe pain on pressure or percussion Pain usually spontaneous; worse with pressure or percussion Usually no thermal response (when pulp is completely necrotic) Geist & Geist  Acute Apical Abscess Periapical abscess without sinus K04.7 continued Chronic apical periodontitis can revert back to acute apical periodontitis Acute apical abscess can flare up within chronic apical periodontitis Geist & Geist  Apical Abscess: acute or chronic Periapical abscess with or without sinus Acute apical Acute apical abscess abscess Chronic apical with radiological with abscess with findings (arises from minimal or fistula formation chronic apical no and clinically periodontitis) radiological present with findings Geist and Geist opening of fistula  Apical Abscess: acute or chronic Periapical abscess with or without sinus Histology: Neutrophils dominate, edema, pus Radiography: Slight to moderate widening of PDL (depending on duration of the lesion) Obvious radiolucency when arising from chronic apical periodontitis or chronic apical abscess Geist & Geist  Treatment of Acute Apical Abscess Palliative treatment: Removal of necrotic pulpal tissue to provide drainage, or pain medication Definitive treatment: Endodontic therapy or extraction MUST establish drainage of pus (even it is microscopic drainage, the drainage can be achieved by removal of the necrotic pulp tissue) Geist & Geist Acute Apical Abscess Periapical abscess without sinus K04.7 An example of AAA arising in a pre-existing chronic apical abscess or chronic apical periodontitis (indicated by large periapical radiolucency) Geist & Geist  Apical Abscess: acute or chronic Periapical abscess with or without sinus Can progress to a dentoalveolar abscess When progressing to a dentoalveolar abscess, the abscess is still localized and can be easily drained. Inflammation is intense in this stage Can progress to fascial space infection and sometimes can be fatal, e.g., Ludwig’s angina Can progress to CAP or CAA Geist & Geist  ICD-10 CM code K12.2 cellulitis and abscess of the mouth include: Abscess of buccal cavity (cheek) Abscess of mouth Abscess of oral tissue Abscess of sublingual space Abscess of submandibular region Cellulitis of floor of mouth Cellulitis of oral soft tissues Cellulitis of submandibular region Inflammation of uvula Ludwig's angina Ludwigs angina Sublingual region abscess Submandibular region abscess Uvulitis Dentoalveolar Abscess ICD-10-CM code K12.2 The abscess can penetrate through the periosteum and be abscess localized by the nearby local upper molar muscle attachments and form an abscess in the soft tissue spaces such as the vestibular space: the potential space between the oral vestibular mucosa and the nearby muscles of facial expression. lower molar This is called a dentoalveolar abscess  Dentoalveolar Abscess This dentoalveolar abscess can be easily drained because of the presence of fluctuation  Dentoalveolar Abscess ICD-10-CM code K12.2 This dentoalveolar abscess can be easily drained because of the presence of fluctuation Geist & Geist Dentoalveolar Abscess ICD-10-CM code K12.2 #30 Dentoalveolar abscess from the right mandibular first molar (#30), arising from chronic Geist & Geist apical periodontitis  Dentoalveolar Abscess ICD-10-CM code K12.2 #19 Dentoalveolar abscess from the left mandibular first molar (#19), arising from chronic apical periodontitis Geist & Geist  Outcome of Dentoalveolar Abscess At the stage of the dentoalveolar abscess the infection is still confined by the fascia and muscle It can be resolved with adequate treatment: – Incision and drainage (as palliative treatment, only provides temporary relief) – Tooth extraction and I&D (definitive treatment) – Root canal therapy after I&D (definitive treatment) Antibiotics are usually not necessary in the immune competent patient Geist & Geist  Outcome of Dentoalveolar Abscess (continued) Once it extends beyond the fascia and muscles, the dentoalveolar abscess can enter the deep fascial spaces such as the subcutaneous space, buccal space, sublingual space, submandibular space, submental space, masticator space, parotid space, lateral pharyngeal space, retropharyngeal space This can lead to a deep neck abscess Treatment can be difficult, often requiring surgical drainage and extensive antibiotic treatment in addition of removing the infection source (increased risk of morbidity) This causes an increased risk of mortality  Fascial Space Infection Fascial space infection: buccal, submandibular, sublingual, submental, infraorbital, zygomaticotemporal, and parapharyngeal spaces Courtersy of Dr. Lena Saleh Geist & Geist  Chronic Apical Periodontitis (CAP) Chronic inflammation at apex of non-vital tooth as a result of pulpal necrosis Occurs over a long time (chronic) Histology: – Chronically inflamed granulation tissue (periapical granuloma) – Cyst cavity lined with epithelium from rests of Malassez (periapical or radicular cyst) Radiography: poorly defined radiolucency extending from PDL into alveolar bone Geist & Geist  Chronic Apical Periodontitis (CAP) Radiolucency at apex of mesial-buccal root of tooth #15 Pulp has been devitalized due to decay #15 The hypodensity (radiolucent) area can be radicular granuloma or cyst, to be determined by biopsy (histologic exam)  Chronic Apical Periodontitis (CAP) K04.5 Chronic inflammatory lesions at apices of tooth #19 Pulp devitalized due to decay and subsequent loss of #19 crown Noted the PARL  Chronic Apical Abscess (CAA) Periapical abscess with sinus K04.6 Chronic inflammatory reaction to pulpal inflammation and necrosis Slow in onset but persistent Usually asymptomatic  Chronic Apical Abscess (CAA) continued Discharge of pus through a fistula with clinical manifestation of an opening on the gingiva Radiography: poorly defined radiolucency near the root apex Histology: neutrophils and pus amidst granulation tissue  Periapical abscess with sinus [Chronic Apical Abscess (CAA)] Continued Chronic apical abscess has a fistula and a periapical Opening of the radiolucency sinus Geist & Geist  Chronic Apical Abscess (#7) #7 Gingival opening (arrow) of a fistula from the radiolucent lesion at the apex of the lateral incisor (#7) Geist & Geist  Chronic Apical Abscess The fistula can be traced with a radiopaque gutta percha point to its origin at the apex of the tooth Geist & Geist  Chronic Apical Abscess #3 #3 Two openings of fistula on the buccal gingiva from two separate roots of the maxillary right first molar (#3) Geist & Geist  Condensing Osteitis- a radiographic term A variant of CAP Usually no symptoms or signs Radiography: poorly defined radiopacity surrounding the apices of the roots Histology: dense bone with scanty inflammatory cells Geist & Geist  Condensing Osteitis #18 Condensing osteitis at apical end of second molar (#18) root It is characterized by a poorly defined radiopacity around the root apices Geist & Geist  All chronic lesions can become acute –a dynamic nature When this happens the patient will have acute symptoms and signs However, the radiographic appearance bears chronic characteristics The clinical diagnosis is dictated by the clinical signs and symptoms, not the radiographic findings But the radiographic findings can support the clinical diagnosis Geist & Geist  All chronic lesions can become acute – a dynamic nature #16 Third episode of abscess arising in a pre-existing chronic apical periodontitis of the maxillary left third molar Geist & Geist  Osteomyelitis Osteomyelitis of the jaw M27.2 Inflammation of bone medullary spaces Usually arises from odontogenic infection as a result of dental decay Not confined to root apices Increased risk in individuals with immune dysfunction: AIDS, leukemia, diabetes, alcoholism, etc. Increased risk in individuals with bone disease such as Paget disease and osteopetrosis Geist & Geist  Osteomyelitis of the Jaw M27.2 Radiography: – Poorly defined, irregular radiolucency – Chronic lesions have interspersed radiopaque foci of non-viable bone Histology: – Chronic or subacutely inflamed granulation tissue, pus, bacteria – Non-viable bone in chronic lesions Geist & Geist A case of osteomyelitis of the jaw September 2008 36-year-old woman complained of a toothache and swelling of the face, treated with antibiotics May 2009 Patient returned with pain; tooth was extracted Patient returned with pain and June 2009 numbness of the lower lip Geist & Geist A case of osteomyelitis (continued) June 2009 February 2010 Panoramic radiograph in June compared to radiograph 8 months later when patient again complained of swollen face and foul taste in mouth Geist & Geist  Caries limited to enamel Caries penetrating into dentin Caries penetrating into pulp pulpitis Acute apical Chronic apical periodontitis periodontitis ICD-10-CM Acute Chronic ICD-10-CM Periapical abscess apical apical Periapical abscess without sinus abscess abscess with sinus Dentoalveolar abscess Osteomylitis Abscess in fascial spaces  Dental Decay in Patients with Diabetes Is the outcome worse than in non- diabetes patients? What is the mechanism? Studies have shown that pulpal inflammation tends to be more intense and progresses to apical periodontitis faster in individuals with uncontrolled diabetes; the inflammation can also make glycemic control difficult (Bender IB 2003). Microvasculopathy and neutrophil function defects have been proposed as the mechanism Geist & Geist  Dental Decay in Patients Who have Diabetes Studies have shown that apical lesions are more prevalent in diabetes patients: “Type 2 DM is significantly associated with an increased prevalence of apical periodontitis (AP).” (Segura-Egea 2005) “Type 2 DM is significantly associated with an increased prevalence of AP and endodontic treatment.” (Lopez-Lopez 2011) Geist & Geist  Apical Lesions in Diabetes Research has shown that in patients with diabetes, there is reduced success rate of endodontic treatment of dental decay-related apical lesions (Fouad AF, 2003) Geist & Geist  Early Detection and Treatment of Dental Decay Interception of dental caries in the early stage in diabetes patients is the primary goal of dental care in this population because current evidence suggests that once the decay advances to the pulp the treatment success rate is significantly reduced Apical lesions tend to flare up frequently in correlation with periods of suboptimal glycemic control Geist & Geist  Example: A 46-year-old African-American female wanted to have complete dentures. She stated that she is diabetic and is “under control.” However, she had bouts of abscess formation whenever she stopped her diabetes medication Purulent discharge from mucobuccal fold Radiograph shows a residual infection in the alveolar bone as the source of her bouts of abscess Geist & Geist  Example: Suboptimal glycemic control causing a flare-up of the apical lesion in tooth #12 #12 Geist & Geist  Dental Infection and Glycemic Control in Diabetes When a chronic apical infection flares into an acute dentoalveolar abscess or beyond, it often has a negative impact on the patient’s glycemic control, making the usual dosage of medication insufficient to bring the blood sugar level down Geist & Geist  Example The patient had a flare-up from chronic apical periodontitis Blood sugar level was elevated Geist & Geist  Deep Neck Infection Deep neck infection refers to infection in the fascial spaces of the neck Odontogenic infection is the most common cause of deep neck infections (Parhicar A 2001, Huang TT 2004, Lee YQ 2011); it spreads from the infection foci in the maxilla or mandible into the sublingual, submental, or submaxillary(submandibular) spaces and then to the spaces in the neck. DM is the most common systemic condition in patients with deep neck infection (Huang TT 2005, Lee YQ 2011) About 1/3 of odontogenic deep neck infection patients have diabetes (Rao DD, 2010) Geist & Geist  Deep Neck Infections in Diabetes Patients DM patients with deep neck infection tend to have extended fascial space involvement in multiple sites (Ludwig’s angina and parapharyngeal infections) (Rao DD 2010, Chen MK 2000, Huang TT 2005) Deep neck infection tends to form abscesses more often in DM patients than non-DM patients and requires surgical drainage (Huang TT, 2005) DM patients suffer more complications, such as airway obstruction, sepsis, or internal jugular vein thrombosis, and longer hospital stays (Huang TT 2005, Rao DD, 2010) Mortality rate of deep neck infection is higher in DM patients Geist & Geist  Odontogenic Infections in Diabetes Patients Unlike other infections such as pneumonia or meningitis, odontogenic infections are treated surgically to remove the source of infection Even in deep neck infections with surgical intervention, removal of the infection source is the most important treatment, especially in patients with diabetes There are clear indications that collaborative and coordinated dental care is essential to optimize the outcome of the treatment Geist & Geist  General Principles in Managing Acute Dental Infections in Diabetes Glycemic control: keep random blood sugar levels below 200 mg/dl (11.1 mmol/l) Treat infection aggressively by removing infection source: – Thorough pulpal debridement or extraction – Incision and drainage if applicable – Antibiotic therapy Treat infection early to minimize the risk of deep neck infection Geist & Geist  General Principles in Managing Chronic Dental Infections in Diabetes Prioritize the chronic dental infections (such as CAP, CAA, chronic osteomyelitis) even through they may be asymptomatic Maintain glycemic control Remove infection source (thorough root canal therapy or tooth extraction) as soon as possible Consider defer the extraction and other surgical procedures when perioperative blood sugar is above 200 mg/dl to minimize the risk of surgical site infection (Berríos-Torres SI, 2017 CDC guideline) Geist & Geist  References: Bender IB. and Bender AB, Diabetes mellitus and the dental pulp J Endod. 2003 Jun;29(6):383-9. 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JAMA Surg. 2017;152(8):784–791 Geist & Geist Endodontic Diagnosis James K. Bahcall, DMD, MS, FICD, FACD Cracked Tooth Syndrome K03.81  Tooth #31, Spontaneous pain aggregated by cold drink, no pain on percussion Geist & Geist Geist & Geist Geist & Geist Geist & Geist  What’s wrong with this patient’s teeth? matted? Not glossy? Demineralization? Remineralization? Or?????? Arrested caries??? Or something else??  Dental fluorosis- caries resistant Enamel defects (from white, chalky area to dark brown discoloration, to even pits) due to ingestion of excessive amount of fluoride during enamel development. Currently, the fluoride concentration in the public water supply is 0.7 ppm. Is it dental fluorosis? What is the supporting evidence? Dental fluorosis? Tetracycline stain? Enamel hypoplasia due to __________ Dental Erosion, often noted in GERD Wells or concavities on the occlusal or incisal surface Often combined with attrition Dental Erosion, often noted in GERD Wells or concavities on the occlusal or incisal surface Often combined with attrition