Odessa National Medical University

Department of Therapeutic Dentistry

methodical recommendations for practical training for students

Discipline "Therapeutic dentistry"

 SECTION 3 "Disorders of the oral mucosa. Deepening of clinical thinking of students. Current methods of examination, diagnosis, differential diagnosis, treatment and prevention of major dental diseases. D ispanserizatsiya patients " Lesson number 35 "Differential diagnosis of periodontitis. X-ray diagnostics. Mistakes and complications in diagnostic. "

              course 5                               The faculty      Dental    

  

Approved byon the methodical meeting of the Department

27.08.2020Protocol number 1

                                                 Head. the Department of ____________                                                Prof. Skiba V.Y.

  

   

Odessa - 2020 

SECTION 3 "Diseases of the oral mucosa. Deepening of clinical thinking of students. Current methods of examination, diagnosis, differential diagnosis, treatment and preventionof major dental diseases. D ispanserizatsiya patients " Lesson number 35 "Differential diagnosis of periodontitis. X-ray diagnostics. Errors and complications in the diagnosis of pulpitis and periodontitis. " 1. Relevance of the topic               Despite Major advances in the treatment of dental caries, periodontal disease is very common. The success of timely diagnosis and treatment largely depends on the knowledge and skills of a comprehensive examination of patients.              Differential diagnosis and x-ray diagnosis of periodontitis is an important step in the definitive diagnosis for diseases of the periodontal tissues. Knowledge of the clinic of similar diseases with periodontitis and changes in the bone tissue of the alveolar process of the jaw is of great importance in conducting clinical and additional methods of examining the patient. To avoid errors in the definitive diagnosis of periodontitis pelpitov and physician report has to conduct clinical studies and additional methods to some ofthe sequence and in full, using the modern techniques and devices. 3. Lesson Objectives:3.1. General objectives:

- to review key E principles differential di agnostic periodontitis

- oznakomitisya with the basic methods in X-ray diagnostics periodontitis;

 

3.2. Learning Objectives:- To learn the ability to explain the patient about the need for timely sanitation of the oral cavity;- To learn the ability to establish close contact with the patient;- To master the principles of medical ethics and deontology3.3. Specific objectives:- to know:- clinic of chronic and acute h ECK them in claim eriodontito;- methods of clinical examination of patients and the additional;- basic PRINCIPLE dif f e differential di- agnostics;- based on the principles rentgendi agnostics;- to know the errors and complications in the diagnosis of pulps itov and periodontitis. 3.4. On the basis of theoretical REPRESENTATIONS receptacle on the topic:- to master the methods / to be able /: - be able to visually assess the patient's condition, identify the presence of pathological changes; - to conduct a survey of the patient; 

             - conduct an examination of the oral cavity; - hold the EOD; - to evaluate the data rentgensni microamperes; - carry out differential diagnostics 4. Materials doauditornoї self-training (interdisciplinary  integration). 

No.Item / n

Distsipli on Know Be able to

1. Previous disciplines:A) Chair of Histology, Embryology and Cytology

B) Department of Pathological Physiology

C) Department of Pathological Anatomy

Histological structure of periodontal disease;Embryonic development of periodontal disease.

Pathophysiological mechanisms of inflammation, the features of the course of the inflammatory process in periodontium, changes in periodontium under the influence of irritating factors.

The main morphological signs of inflammation;The main components of inflammation (alteration, exudation, proliferation).

Cook:-Histological preparations, determine the type of tissues;- Prepare drugs, evaluate the data of cytology.

estimate:Pathophysiological changes in periodontium.

Identify and evaluate the elements of inflammation in periodontium.

2. Last eduyuschie discipline:A) dentistry of childhood.

The mechanism of development of acute and chronic forms of periodontitis;The main clinical signs of acute and chronic forms of periodontitis;Principles of differential diagnostics.

Conduct an examination of the oral cavity;

3. Intra-subject integration:

Mechanical gpozniknoveniya in major clinical signs;Principles of differential diagnosis of the disease

Conduct a consistent examination of the oral cavity, the dentition.Conduct X-ray analysis.

 5. Content of the topic.

Contents of the lessonAcute periodontitis differentiated from acute pulpitis, periostitis, osteomyelitis

of the jaw, suppuration to the Neva cysts, acute odontogenic maxillary sinusitis. In contrast to pulpitis, with acute periodontitis, pain is constant, with diffuse inflammation of the pulp paroxysmal. In acute periodontitis, in contrast to acute pulpitis, there are inflammatory changes in the gum adjacent to the tooth, percussion is more painful. In addition, the diagnostics are assisted by the data of electrodonoimetry. Differential diagnosis of acute periodontitis and acute purulent periostitis of the jaw is based on more pronounced complaints, febrile reaction, the presence of collateral inflammatory edema, peri-axial soft tissues and diffuse infiltration along the jaw transitional fold with the formation of the subperiosteal ulcer. Percussion of the tooth with periostitis of the jaw is not very painful, unlike acute periodontitis. For the same, more pronounced general and local symptoms, differential diagnosis of acute periodontitis and acute osteomyelitis is performed.  

For acute osteomyelitis of the jaw, inflammatory changes of the adjacent soft tissues on both sides of the alveolar process and the jaw body are characteristic.  

With acute periodontitis percussion is sharply painful in the area of one tooth, with osteomyelitis of several teeth. And the tooth, which was the source of the disease, reacts to percussion less than neighboring intact teeth. Laboratory data leukocytosis, ESR, etc. allow to distinguish between these diseases.

Purulent periodontitis should be differentiated from suppuration of the circumcortical cyst. The presence of a limited swelling of the alveolar process, sometimes the absence of a bone in the center of the bone, the displacement of the teeth, in contrast to acute periodontitis, characterize the overgrown cirrus cyst. On the roentgenogram, a portion of bone resorption of round or oval shape is found in the cyst.

Acute purulent periodontitis must be differentiated from acute odontogenic inflammation of the maxillary sinus, in which pain can develop in one or more adjacent teeth.However, the congestion of the corresponding half of the nose, purulent discharge from the nasal passage, headache, general malaise are characteristic of acute inflammation of the maxillary sinus. Infringement of a transparency of the maxillary sinus, revealed on the roentgenogram, allows to specify the diagnosis.

Chronic periodontitis g ranuliruyuschy should be differentiated from radicular cysts, chronic osteomyelitis of the jaw, fistulas face and neck, actinomycosis. With granulating periodontitis with subperiosteal granuloma and near-root cyst, there is a swelling of the alveolar process. However, cyst displacement is observed in the cyst, sometimes there is no bone in the area of bulging, and on the roentgenogram there is a bone resorption site of considerable size with clear, even contours.

The presence of a fistula on the face, the mucous membrane of the oral cavity, suppuration from it cause the similarity of granulating periodontitis and limited osteomyelitis of the jaw. However, odontogenic osteomyelitis of the jaw is characterized by an acute stage of the disease, accompanied by symptoms of intoxication. In the chronic stage, on the roentgenogram, foci of bone resorption are

found, in the center of which shadows are sequesters. Neighboring intact teeth become mobile.

Fistulas on the face and neck with granulating periodontitis may resemble brachyogenic formations. Correct diagnosis is facilitated by fusion sounding, x-ray of the tooth, fistulography of the branchy fistula.

There are similar fistulas in chronic granulating periodontitis and actinomycosis of the face and neck. However, with chronic periodontitis, fistula is single, with actinomycosis fistulas are located in the center of different or individual small infiltrates. The study of the detachable and the finding of actinomycete druses with actinomycosis help differentiate the inflammatory diseases. Tuberculosis foci, as a rule, are multiple, not connected with the jaw and teeth. Characteristic are the allocation of dense cottage cheese among them. At the site of the tuberculosis foci are characteristic zve zdchatoy form scars. Microscopy, cytology and m orfologicheskie study poses the will of a correct diagnosis.

Chronic granulomatous periodontitis should be differentiated from the circumcision cyst, especially when the cortical plate of the alveolar process is bulging. On the radiograph in granulomatous periodontitis exhibit bone resorption portion 0.5 - 0.7 cm. Diameter, with a cyst, a significant resorption of the bone with clear contours is visible.  

HECM rubbing on bright m s clinical symptom of acute purulent periostitis jaw by its diagnostic sometimes make mistakes. This process should be differentiated from acute purulent periodontitis, abscess s series of localization, abscesses, lymphadenitis, acute sialadenitis and acute osteomyelitis of the jaw. The difference from periodontitis periodontitis determined by the localization inflammatory focus, when n takes the last one within the cavity, and periostitis on the surface of alveolar process. Collateral edema with periodontitis is limited to the gum, not extending to soft tissue.

Differentiation between periostitis and osteomyelitis justified character clinical course and lack of bone lesions in periostitis as formation sequesters and microscopic changes to the structure of the spine.

In addition, unlike acute periodontitis with acute periostitis of the jaw pain sensitivity with percussion of the tooth, which was the source of infection, is absent Or insignificant. Inflammation of mucosa and transitional fold at the stop rum periodontitis are in the form of swelling, periostitis and in acute inflammatory infiltration jaw. In acute periodontitis, in contrast to purulent periostitis, when the periosteum is dissected, pus is not detected.

Differential diagnosis east cerned periostitis of the jaw from purulent lesions salivary glands based on the fact that in acute inflammation of the parotid and submandibular salivary glands palpable dense painful I swollen gland deep in the tissues, and allocates camping festering secret of its channels in.

Acute purulent periostitis must be differentiated from acute osteomyelitis of the jaw. For p ost th osteomyelitis jaw characteristic expressed intoxication: type febrile reaction temperature, headache, fatigue, weakness, fever, sweats and other reaction regional lymph nodes was more pronounced.. Periostal thickening of the bone is observed on both sides of the jaw: inflammatory changes in the mucosa occur both in the mouth and in the oral cavity. Percussion of several teeth according to the site of the affected bone is painful, and they are mobile. On the lower jaw with

osteomyelitis, the numbness of the lower lip and chin skin of Vincent's syndrome is diagnosed.

Acute periostitis jaw differentiate from suppurative diseases of soft tissues admaxillary, abscess, phlegmon, lymphadenitis. With periostitis, the tissues are swollen and soft to the touch, with abscess, phlegmon, lymphadenitis, dense, limited or diffuse infiltration is palpable. If an abscess or phlegmon is located in the superficial areas of the face and neck adjacent to the upper and lower jaw, the skin above the infiltrate is soldered, glossy and hyperemic When the deep areas of the face are damaged in the tissues visible from the external examination, perifocal edema is recorded, but unlike periostitis there are no characteristic changes in the transitional fold.

Particular difficulties for differential diagnosis are the periostitis of the lower jaw from the lingual side and the abscess of the anterior part of the hyoid area or the posterior part of the maxillofacial groove. With suppurative processes in the anterior and posterior parts of the hyoid area, an enlarged hyoid bead is seen due to a dense and painful infiltrate. In the abscess of the maxillofacial groove, opening the mouth is limited and swallowing is painful. However, as with periostitis, the infiltrate is located along the alveolar process, the opening of the mouth is often not limited.

Periostitis of the lower jaw from the lingual side can be mistaken for inflammation of the duct of the submandibular salivary gland, but when the salivary stone is located in the duct, the infiltrate is located on its way, thick viscous saliva or a purulent-mucous secret is released from the outlet. With palpation, you can determine the foreign body and then confirm it radiologically. With periostitis, localization of the infiltrate and the presence of pure saliva allow you to refute the diagnosis of sialadenitis.

Acute, subacute, and chronic stage osteomyelitis jaw and exacerbation of chronic peri odontita should be differentiated from the specific, odontogenic inflammatory diseases, tumors and tumor formations. The acute phase Odontogenic osteomyelitis must be differentiated from acute or exacerbation of chronic periodontitis. Gen eral Kar Tina disease calm me, the focus of inflammation only in the area of the tooth, the intactness of the periosteum and soft tissue admaxillary are the main distinguishing features of periodontal osteomyelitis.

In acute purulent n eriostite and acute osteomyelitis jaw observed violations of the general condition, temperature reaction, changes in the blood, the process begins with a progressive inflammation in odontogenic focus. However, in acute osteomyelitis, in contrast to periostitis, the signs of intoxication are more pronounced and when viewed from the oral cavity, inflammatory phenomena are seen in the periosteum on both sides of the jaw, there are signs of acute periodontitis of several teeth according to the site of the affected bone. Furthermore, when periostitis after tooth extraction, emptying the hearth subperiosteal inflammatory phenomena are eliminated within 3 - 5 days.

Osteomyelitis of the jaw complicated by phlegmon is differentiated from abscesses and phlegmon. A characteristic feature of these diseases is the onset of the disease: the inflammatory signs osteoflegmone focus lies in the region of teeth, periosteum, alveolar bone and the jaw body, then passes into soft tissue, abscesses and phlegmons inflammatory changes are located only in the soft tissues.

Xp onichesky differentiate osteomyelitis from specific lesions: actinomycosis, tuberculosis, syphilis. The acute onset of the disease, marked signs of intoxication for specific bone lesions are not characteristic. Help in the diagnosis and determination of selection by seeding specific pathogens, and specific skin reactions in tuberculosis, actinomycosis e,e syphilis serodiagnosis while chronic osteomyelitis of the jaw must be differentiated from the tumors and tumor conditions fibrous dysplasia, malignant tumor. Acute onset process phenomena of intoxication, changes in blood and urine observed in osteomyelitis for fibrous dysplasia and sarcomas are not characteristic, in the diagnosis and cytological resorted to pathomorphological studies.

 Acute serous periodontitis Acute focal pulpitis

The increasing steady increasing Irritability does not affect pain Sensation painless  The mucous membrane of the transient fold is changed The threshold of electrical excitability is more than 100 μA

Pain spontaneous paroxysmal Irritants intensify pain Probing is painful  The mucous membrane of the transitional fold is not changed  The threshold of electrical excitability is 20-30 μA

Acute purulent periodontitis Acute diffuse pulpitisPains of spontaneous constants Pain localized in one tooth Sensation painless  There are changes in the mucous membrane of the transitional fold The threshold of electrical excitability is more than 100 μA There are changes on the roentgenogram The general condition is greatly affected

Pain spontaneous paroxysmal Pain radiates along the trigeminal nerve tract Probing is painful  The mucous membrane of the transitional fold is not changed The threshold of electrical excitability is 40-60 μA There are no changes on the roentgenogram The general condition is not broken

Chronic fibrous periodontitis Chronic middle cariesTooth color changed Probing is painless, the entrance to the tooth cavity is often determined  Temperature tests are not expressed The threshold of electrical excitability is more than 100 μA There are changes on the roentgenogram

The color of the tooth is not changed Probing slightly painful Temperature tests are expressed Electroexcitability a threshold 2-6 microamps changes on chest radiograph no

Chronic granulating periodontitis Chronic gangrenous pulpitisPain sluggish spontaneous sounding mouths painless channels . Thermal stimuli do not cause pain There mucosa change threshold electroexcitability than 100 uA 

Pain from the hot probing channel mouths painful Hot enhances pain mucosa is not changed electroexcitability threshold 60 microamps 

always detected radiographic changes suffers overall

changes on X-ray detected in 30-45% of cases, general condition is not violated

Chronic granulomatous periodontitis Chronic fibrous first pulpitPain minor tooth color changed input Probing painless tooth cavity in Reaction to stimuli is no threshold electroexcitability above 100 uA There changes retgenologicheskie 

There are pain from the impact of the stimuli of the tooth color changes input Probing into the tooth cavity Temperature probe painful cause pain electroexcitability threshold 20-30 microamps changes on radiographs are found in 10-25% of cases 

 

Diagnostics of periodontitis on an X-ray   -              So to ak chronic periodontitis is the destruction of the bone in the apex

formation and periodontal abscess (purulent pouch, densely attached to the root apex), then on a roentgen such area will appear as a sharp band at the dimming apex.              On   Figure 8   -   You can see the chronic periodontitis, which arose due to the fact that the sealed root canal dentist not to apex. Nedoplombirovannaya part of the channel is shown by a white arrow, and the boundaries of periapical abscess - black.              On   Figure 9 - You can see the cyst tooth previously treated for caries. Cysts also belong to such disease like periodontitis. On   Figure 10 - you can see the focus of blackout at the apex of the root, which also indicates the presence of periapical abscess. Therefore here also we can say about chronic periodontitis . 

          

1.   Not timely cured dental pulp    -

Figure 11 You can see schematically a cavity from which the infection has penetrated first into the pulp of the tooth, and then through the holes of a root canal

on the tops of the roots of the infection gets into periodontitis, causing the formation of a periodontal abscess there (purulent sac).On the X-ray you can see how a cavity and periodontal abscess itself at the apex of the root (darkening at the root apex highlighted in yellow circle). Periodontal abscess is very rentgenokontasten, and so it is always good to be seen.

2.   Poorly lead sealed root canals    -If the treatment of pulpitis root canals were not are sealed to the root apex, it is not sealed section of duct infection develops. Over time, the infection beyond the tooth, causing the formation of a periodontal abscess at the apex.On   ris.8,12 you can see it looks like on X-ray periodontitis, arising from the fact that the dentist poorly the sealed root canals. H ezaplombirovannaya portion of the channel contains the white arrow and black arrows indicate the border of periodontal abscess, which looks like an intense darkening in the tops of the tooth roots .   

.  The emergence of periodontitis in the tooth for a crown    - because before prosthetic teeth crowns in most cases depulpiruyutsya, the poor quality of root canal filling in preparation for prosthetics - very often leads to the

development of periodontitis. Thus, periodontitis under crown - a consequence of poor dental work at sealing the root canal. On   Figure 13 you can see a schematic representation of how periodontal abscess occurs when the root canal is not sealed to the top of the root.    On   Figure 14. You can see the X-ray diffraction, which is shown by white arrows nezaplombirovannaya part of the root canal, and the black arrows show the boundaries of periodontal abscess, which is on the X-ray looks like a heavy blackout in the area of the root tip. 

    For completeness, it should be noted that under the crown of periodontitis can occur not only in poorly sealed ducts, but also when taken alive tooth for a crown. Already after a tooth is fixed on the crown - can occur destruction of the tooth pulp, leading first to the development of pulpitis and pulp death, and then to the development of periodontitis. The cause of death of the pulp may be, for example, its thermal burns during the turning of the tooth for a crown. The latter circumstance is also no more than a mistake doctor. 

3.   marginal periodontitis   -              When ne   p   and   odonto moderate and severe  between the root and the bone second fabric formed deep ne p and odontalnye pockets. Infection of these pockets is able to extend deeper on the periodontium, penetrating to the tops of the roots. Due to the fact that the infection penetrates the apex region of the oral cavity, extending along the depth of the root - this is called marginal periodontitis.               On   Figure 15 you can see the scheme of development of marginal periodontitis in the event of the interior of the FIR n, p and odontalnyh pockets. On radiographs (around one of the upper incisors), we can see the intense darkening, going along the root from the neck of the tooth and to the apex. This is nothing like a deep n, p and odontalny pocket. Arrow shows the path of infection in the region of the root apex. In the top of the root is also the case blackout, which indicates the beginning of the formation of a periodontal abscess. 

     

On   Fig.16 shows the appearance of the tooth 21 (X-ray diffraction is shown in Figure 15). As you can see: from under the gums copious purulent discharge is released when pressure; the crown of the tooth is completely amazed caries process . 

4.   traumatic periodontitis   -              It refers to periodontal infectious origin. There is a one-stage or from home, a sports injury - in this case we speak of acute traumatic periodontitis, or by permanent the permanent traumatic effects - in this case we speak of chronic traumatic periodontitis.Acute traumatic periodontitis clinically may appear:                              tooth dislocation   - 

It accompanied tooth mobility and pain during biting on the tooth.                              Rupture of the neurovascular bundle   - 

in this case the tooth is also flexible + tooth crown is colored in pink,                              Fracture of the root.              Occurrence of chronic periodontitis associated with traumatic tooth overload as a result of errors in the treatment and prosthetics. For example, when inflated SRI seal height is not uniform between teeth and premature nakusyvanii one of the teeth. When chewing a tooth will be highly stressed than the other teeth. This constant chronic trauma can lead to traumatic periodontitis.

5.   medical periodontitis   -

              Also refers to periodontal infectious origin. Develops as a result of exposure to, for example, potent antiseptics (parkan, etc.) on the periodontal tissue in the treatment of pulpitis, i.e. during processing and root canal filling. Also this form of periodontal disease can be a manifestation of an allergic reaction, for example, one of the components of the paste (sealer) for sealing root canals.              To medical periodontitis also applies arsenic periodontitis. This form of periodontitis is caused by an excessively-long exposure arsenous paste on tooth tissues. Previously, when there was a good anesthetic, arsenic was widely used to kill the pulp of the tooth, and then safely remove it and seal the channels. Now, high-performance anesthetics used in dentistry, the use of which has allowed almost completely renounce the use of arsenic. Errors and Oslo zhneniya in the diagnosis of pulpitis and periodontitis               Errors in diagnosis pulpitis associated with poor medical history, symptoms and misjudgment of the degree of inflammation of the pulp prevalence underestimation of pain symptoms.                      Identifying new pulpitis teeth diagnostic methods should take into account features of the structure and functioning of the dental pulp, etiology, pathogenesis and course of the inflammatory process.              Each tooth is subject to periodic th , preventive, clinical and radiological monitoring to detect possible pathological processes of the jaws .              Periodontitis still occupy in practice a significant place dentists . Despite the fact that the diagnosis of periodontitis is well developed, nevertheless erred in making a diagnosis. They occur when the disease does not differentiate the regional (marginal) and apical (apical) periodontal. In this case, errors may be associated with symptoms misjudgment marginal periodontal inflammation.              Checking one symptom that is not sharply pronounced (percussion pain on the side of the tooth), the doctor does not give it value. At the same time a thorough X-ray examination, examination of periodontal pockets is shown in these cases, the presence of the process in the periodontal region. When X-ray is not always easy to differentiate between periodontal disease and periodontitis . Elucidation of the etiology and pathogenesis of the disease, the determination of tooth stability, dynamic monitoring allow properly establish the diagnosis. There may be errors in the diagnosis of periodontal disease apical when process exacerbation occurs. It is necessary to decide whether an acute exacerbation of chronic periodontitis or periodontitis has, as a treatment process is different. For the final diagnosis is set to X-ray examination. The absence of marked changes in bone suggest that the process of acute and developed for the first time. A violation pattern bone rarefaction portions expansion characteristic of the periodontal ligament chronic process in the acute stage. It is not easy to solve the problem in establishing the diagnosis of periodontitis multi-rooted teeth. It is known that chronic periodontitis in the roots of certain pulp remains alive and even maloizmenennoy. In this connection, use a combination of therapies. To avoid errors in the determination of the state of the pulp in chronic periodontitis multi-rooted teeth need to scrutinize the pulp in each channel by

electrometric and thermal methods, and X-ray data analysis. Especially the care and attention needed to conduct a study of the teeth of the upper jaw. The presence of inflammation in the maxillary sinus, the sky can give the same symptoms as in periodontitis. Survey by eliminating signs typical of sinusitis, for processes in the sky helps to avoid mistakes in the diagnosis of periodontal disease. In a study of the state of periodontal error can be tolerated, if one even dominant symptom attach primary importance. It must be remembered that the apical periodontal closely associated with the surrounding tissues, adjacent teeth, has an extensive network of nerves and blood vessels, and therefore the periodontal lesion symptoms may be a variety of other disorders: alveolar bone (interdental partitions), adjacent teeth, soft tissues , neuralgia, and so on. If in doubt, it is recommended to carry out the re-inspection. After 2-3 days, repeat the whole complex examination of the patient, which allows us to determine the true disease. Sometimes holding novocaine blockade may lead to the elimination of associated symptoms.                

                                                                          

  6. M aterialy Methodological eskogo Ensuring the classes . 6.1. Targets for self-starting of knowledge abilities. 1. Patient A. 21 years complains of a constant throbbing pain in growing 27. Objectively: the carious cavity is large is made softened dentin, tooth cavity is closed. Sensing the bottom is not painful . Percussion Ia sharply painful, mobility zu ba 2 tbsp. palpation of the mucosa in the area of the projection 27 causes the tips of the roots of pain.Radiographic changes have been identified. Select the most likely diagnosis is: A. The Exacerbation of chronic periodontitis B. Acute serous periodontitis C. Acute suppurative periodontitis D. Acute diffuse pulpitis E. Acute suppurative pulpitis 

  2. Man 27 years complained of severe throbbing pain in the left upper jaw, which is distributed on the cheek and ear. When rinsing the mouth with cold water pain disappears. On examination revealed deep karyotype of in the cavity in the tooth 27. Sensing the bottom of the cavity 27 and percussion painful. What is the most likely diagnosis is: A. The limited Acute pulpitis B. Acute diffuse Palpa t C. Acute suppurative pulpitis 

D. Acute serous periodontitis E. Pulpitis complicated periodontitis 

3. Patient G. 20 years complains of pain and bleeding in the tooth 36 at upotr Blenheim solid food. Objectively : masticatory surface on the medial most carious cavity 36 is formed meaty tumor formation, occurs during the sensing bleeding and soreness in the area of posts carious cavity with pulp Kama swarm. Percussion is not painful. E OD - 40 uA. Radiographic changes were detected. Install diagnosis: A. The chronic papillitis B. epulis C. Chronic hypertrophic pulpitis D. Chronic gangrenous pulpitis E.Hroni chny fibrous pulpitis 

4. The nature of pain in chronic periodontitis granulemetoznomu: A - no pain; In - the pain from thermal stimuli; C - independent periodic pain in the tooth; D - self intense constant pain; E - independent constant aching pain.

5. P olozhitelny symptom "vazopareza " characteristic: A - chronic caries; B - chronic pulpitis; C - a chronic granulating periodontitis; D - chronic periodontitis in the acute stage; E - acute periodontitis

6. The emergence or intensification of pain in chronic periodontitis possible from: A - cold; B - hot; C - sweet; D - when biting ; E - at night. 7. What indicators EDI possible in chronic periodontitis? A - 2 - 6mkA; B - 40 - 60mkA; C - 60 - 80mkA; D - 80 - 100mkA; E - more 100mkA.

8. These objective are examined Hovhan chronic granulomatous periodontitis possible: A - intact tooth, crown darkened; In - the sealed tooth; 

C - the presence of a deep cavity, sensing painless; D - carious cavity, percussion painful; E - all of the above; 

  6.2. Literature for students:- Training

 1. is therapeutic stomatologіya: pіdruch. for students. visch. honey. navch. bookmark. III-IV rіvnіv akreditatsії:. At 4 t / MF Danilevsky, AV Borisenko, AM Polіtun [that іn.] Of red. A. V. Borisenka. T. 4: Zahvoryuvannya slizovoї Ilya Obolonkov porozhnini company, 2010. - 639 p.2. is therapeutic stomatologіya: Pіdruchnik for studentіv stomatologіchnih fakultetіv vischih medichnih The Teaching IV zakladіv rіvnya akreditatsії:. Y 2 t / per Ed. Anatolіya Nіkolіshina. - T. 2. - Poltava: Dyvosvit, 2007 - 280 p.3. Comprehensive practically oriented state exam. [Proc. aid for graduate students of dental surg. factor. Executive. honey. Proc. institutions of Ukraine] / LD Chulak, KN Kosenko AG Gulyuk etc .; Ed. LD Chulak. - Odessa: Odessa State Medical University, 2006. - 194 p.- more1. Lutskaya I. K. Diagnostic dentist directory / I. K. Lutskaya. - M:Honey. lit., 2008 -. 384.2. Antonenko M. Yu Zahvoryuvannya slizovoї Ilya Obolonkov porozhnini company od teorії to practice: dovіdnik lіkarya dentist. / M. Yu Antonenko, A. Borisenko,O. F. Nesin [that іn.]. - K .: TOV "Bіblіoteka" Health Protection of Ukraine ", 2013. - 648 p.3. Therapeutic dentistry: national leadership / ed. LA Dmitrieva, Yu. M. Maksimovskogo - M .: GЄOTAR - Media, 2009. - 588 p. 4. Koval N. I. mouth disease: a textbook / N. I. Koval, A. F. Nesin, E. A. Koval - K .: ENE "Medicine". - 2013. - 344 p.5. Bobir VM Farmakoterapіya in stomatologії / VM Bobir, TA Petrova, T. Yu Ostrovska, MM Ryabushko. - Vinnitsa: Nova Book, 2014 - 368 p.

 6.3. Orienting map for independent work with literature on the topic

of employment. 

№ п / п

Main goals In Kazan About Twet

1.

2.

Explore: Blade , diagnosis

Diff. diagnostics .

Identify the main symptoms of acute and chronic periodontitis .

Create and populate a tabledifferential differential di- agnostic and periodontitis. List the disease the clinical course similar to periodontitis. main clinical signs of acute and chronic forms of pulpitis.

3.

4.

X-ray diagnostics.

Errors and complications

Describe the radiological picture of periodontitis .List the errors and complications in the diagnosis of pulpitis and periodontitis .

  7 . Control materials for the final stage of employment: tasks, assignments, tests . 

A. Questions for self-control .1. The structural features of periodontal. 2. Ways of infection in the periodontium. 3. Classification of periodontitis. 4. What are the main and additional methods of diagnosis of periodontitis. 5. What are the main symptoms of acute forms of periodontitis. 6. What are the main symptoms of chronic periodontitis. 7. What are the main symptoms of chronic periodontitis in the acute stage. 8. Basic principles of differential diagnosis of acute, chronic and acute phase of chronic periodontitis. 9. What are the mistakes and complications in the diagnosis of pulpitis and periodontitis 

B. Tests for self-control with the standards of the responses. 1. Histological description periodontal on transverse section beams usually distinguish dense fibrous tissue composed of closely interwoven sobo minutes collagen fibers tensioned x alveolar process between the cement and tooth root. In different parts of the periodontal gap, these beams have various Noah accommodation. What kind of tension have these beams around the edge of the dental alveolus: A. almost horizontally and form the circular tooth connection B. Kosu stiffly st C. Gori zontally w and braid w stiffly st D. Perez ekayut peri odontalnu th slot in different directions E. circularly orientation

 2. Acute purulent first periodontitis is the outcomeA   acute diffuse pulpitisIn chronic fibrous pulpitisWith tooth injuryA chronic fibrotic periodontitisE. on the page th purulent pulpitis 3. The clinical picture of acute purulent periodontitisA. acutely painful vertical percussion; swelling, redness transition folds, may form subperiosteal or submucosal edema

B. spontaneous, paroxysmal pain, aggravated by irritants and biting on a toothC. fistula on the gums with a purulent dischargeD. nocturnal pain, duration of pain from the hot, EDI up to 60 mAE. acutely painful horizontal percussion 4 . Radiographically chronic periodontitis granulating tapedA. radiolyutsentnye destruction of bone tissue in the periapical region without

precise contoursB. Disorders of bone tissue in the periapical region of round or oval shape with

sharp edges up to 5 mmS. radiolyutsentnye destruction of bone tissue in the periapical region of round or

oval shape with clear boundaries are larger than 1 cm in diameterD. extension of the periodontal ligament at the apexE without having to change the periapical tissues in the vane root5. The dentist conducts the treatment of

chronic granulating periodontitis in women 53 years of age. M edialnye channels obliterated . Which of the below listed medikamentozno sredst in no necessity to choose for the expansion of channels ?

A 2% solution of trypsinB. 20% etilendiaminterrauksusnoy acidC. 10% p-p of hydrogen peroxideD. 10% solution of phosphoric acidE. 45% solution of formaldehyde 6. in a patient 35 years of complaints about permanent aching pain in the tooth 25,

which is enhanced by biting. Objectively: 25 deep carious tooth cavity, which communicates with the cavity of the tooth. Transitional fold in 25 tooth swelling, hyperemic, painful to palpation, percussion sharply painful. After sensing the channel appeared pus. What method of research is needed for a definitive diagnosis.

A. X-ray examination.V. electric pulp testS. thermodiagnosticsD. bacteriological study.Deep probing E. 7. A patient 19 years of pain in the tooth 22, aggravated by biting, jitteriness

"grown up" teeth, swelling of the upper lip. In the history of the patient suffered an injury of the upper jaw in the frontal area. Objectively: 22 tooth intact. Vertical percussion sharply painful. What method of research is needed to make the diagnosis?

A. Transilyuminatsiya.B. EDIS. ReodentografiyaD. RadiographyE. thermometry. 

8. The dentist treats tooth 36 for chronic periodontitis in men 55 years of age. On X-ray revealed that the medial channels are curved in the apex krnya hearth destruction of bone tissue with uneven edges size of 0.2 * 0.2 mm. Which means you need to select midikamentoznoe for intracanal elektoroforeza?

A 1% solution miramistina.B. 1% solution decametoxineC. 1% novocaineD. 10% solution of potassium iodideE. 0.1% solution of trypsin 9. The patient complains of pain in the tooth 26 increasing with biting. From

history: 4 days ago for the treatment of tooth pulpitis 26 was imposed arsenic paste, at a designated time to receive the patient did not show up. Objectively: on the chewing surface of the tooth 26 carious cavity is closed Hermetically sealed bandage, percussion sharply painful. On radiographs in periapical tissues pathological changes not. After removing the bandage, mechanical and medical obrayuotki channels - turundy not wet painted. What medications are best left in the root canal for maximum clinical effect?

A. ChlorhexidineB. UnitiolS. ChloramineD. PeroxideE. Trypsin B. Zada chi for self-control with the answers. 

1 Patient T. complains darkening oronki tooth 12. Objective: to proximal-distal surface 12 of the deep carious tooth cavity tooth chamber is open, sensing, to thermal stimuli reaction painless. Diagnosis was chronic granulomatous periodontitis of 12 tooth. What diseases have to be differentiated on the basis of clinical data? A. Chronic deep caries B. chronic gangrenous pulpitis C. Chronic fibrotic period ontitom D. chronic granulomatous periodontitis E. With all the above mentioned

 2. Patient T. complains darkening 11zuba crowns. Objectively: a tooth 11 on the

medial surface of the large seal made of composite material. On the radiograph 11 tooth root canal not sealable, at the top of the root hearth destruction of bone tissue 3 x 4 mm, with a clear outline. Install diagnosis. A. - Defective sealing tooth 11 V. - Chronic gangrenous pulpitis S. - Chronic periodontitis fibrotic D. - Chronic granulomatous periodontitis E. - Chronic periodontitis granulyuyuchy

3. Patient M.40 years, complains of discomfort in the 26 tooth. Objectively: on the chewing surface of a tooth 26 deep carious cavity, which communicates with the pulp

chamber, sensing thermodiagnostics painless, percussion slightly painful. On the gums in the area of the projection root 2 6 tooth scar Symptom "vazopareza " positive. Select diagnosis, the most appropriate symptoms. A. - Exacerbation of chronic periodontitis V. - Chronic granulomatous periodontitis C - Chronic granuliruyuschi th periodontitis D. The - Chronic gangrenous pulpitis E. - Chronic fibrotic periodontitis

 4. Patient A. 25 years old, came to the doctor for the purpose of

rehabilitation. When X-ray examination of the tooth in the root apex defined hearth bone destruction measuring 3 x 4 mm, with a clear outline. It was put forth iagnoz "grunulematozny Chronic periodontitis." What is the e gen 11 tooth is most likely? A. - 2 - 6 mA B. - -40 20 uA C. - 60 - 80 microamps D. - 80 - 100 uA E. - over 100 microamps

5. The patient is 45 years old, he complained of the presence of a cavity in the tooth 25. The examination found: mucosa at hyperemic tooth 25 on the distal surface 25 of the deep carious tooth cavity that is combined with the pulp pantry. Sensing painless, percussion painful. On X-ray 25 on the tooth root apex hearth bone destruction round shape with a diameter of 4 mm with a clear contour in E. Install diagnosis. A. - Chronic granulomatous periodontitis B. - Kistogranulema S. - Chronic granuliruyusch s periodontitis D. - Chronic gangrenous pulpitis E. - Chronic periodontitis fibrosa

6. Patient 37 years complained of the presence of a cavity in the tooth 34. From history cavity appeared long ago. Objectively: on the chewing surface of a tooth 34 deep carious cavity communicating with the cavity of the tooth. Sensing and percussion painless. On radiographs revealed deformation of the periodontal ligament and extending it into the tops of the roots. What is the most likely diagnosis?

A. Chronic granulating periodontitisB. Chronic fibrotic periodontitisC - Chronic granulomatous periodontitisD. - X ronichesky fibrous pulpitisE. - Chronic gangrenous pulps IT 7. A patient 48 years complains of the presence of cavities in the tooth 26, getting

food, unpleasant sensations, the presence of scar from the cheeks, the presence of the scar on the mucosa in the tops of the roots from the buccal side. From history: previously treated tooth, after a cold aching pain occurs periodically in the tooth. Objectively: a prischechnoy region 26 deep carious tooth cavity, which communicates with the cavity of the tooth. Reaction to the cold, probing and percussion painless. On the gingival mucous membrane in the projection of the tooth

tips of the roots 26 with a large scar buccal side, positive symptom vazopareza. What is the most likely diagnosis?

A. Chronic granulating periodontitisB. X ronichesky deep cariesC - Chronic gangrenous pulps ITD. - X ronichesky granulomatous periodontitisE. - Chronic fibrotic periodontitis 8. The patient in '44 complains of the presence of cavities in the tooth 23, getting

food, change the color of the crown. From history: the tooth was previously treated for pulpitis. Objectively: 23 deep carious tooth cavity III class Black, at the bottom of the remnants of the filling material. Sensing and percussion painless. On gingival mucous membrane in the apex of the projection with the buccal side fistulous opening. On radiographs: in the apex of the tooth root 26 - hearth bone destruction, without clear outlines, the root canal is sealed to ½ length. Put the most likely diagnosis?

A radicular cystB. Chronic fibrotic periodontitisC. X ronichesky granulomatous periodontitisD.Obostrenie chronic periodontitisE. A. Chronic granulating periodontitis Answers to tests and zavachi.

6.1. 1-C, 2-C, 3-C, 4-A, 5-C, 6-D, 7-F, 8-

C,                                                                                                 

B 6.3 .: 1-A, 2-F, 3-A, 4-A, 5-B, 6-A, 7-A, 8-

B                                                                                                 

6.3. In 1-D, 2-D, 3-C, 4-F, 5-A, 6-B, 7-A, 8-

E.                                                                                                  8.Materi Ali for classroom self-study: 

8.1. List of educational practical tasks which must be performed during the practice (of Lab Athorne) classes: 1. determine the dental plan of inspection of patient; 2. carry out basic and advanced inspection methods; 3. The differential diagnosis of periodontitis teeth; 4. conduct radiological diagnostic periodontitis; 5. list the errors and complications in the diagnosis of pulpitis and periodontitis. 

9. Materials of methodical maintenance of the main phase of occupation: n rofessionaln s algorithms, orienting map for the formation of practical skills, learning tasks. 1. Conducting elektroodontodi agnostics. The method is based on the ability of nerve tissue excited by the action of stimuli. Threshold stimulus value is a measure of the degree of excitation, which depends on the state of the pulp. Healthy teeth stroke and others with established roots respond to a current of from 2 to 6 mA (excluding third molars, for which 50% of the current strength above 6 mA). Material ensuring 1.Nabo p dental instruments 2.Aparat e gen (ROW-50) Basic knowledge 1. anatomical and histological structure of the teeth 2. Morphological changes in solid tissue, pulp, tooth with periodontal disease. 3. Clinical caries, pulpitis, periodontal 4. The mechanism of electrical current irritant Indications for E OD Elektroodontometri I can be applied as an additional method of examination for the diagnosis of caries, pulpitis, periodontal and tooth trauma. Contraindications to E OD 1. Severe CNS disease 2. Presence of a pacemaker in a patient 3. The metal seal on a tooth that explores 4. Metal tires in trauma teeth 5. Seal - the restoration occupy the entire chewing surface of the tooth or cutting edge 6. E OD is carried out not earlier than 24 hours after the X-ray inspection electrode etc. and study should be placed at the cutting edge - n and the middle of the cutting edge in canines at the apex buccal protuberance ka , y pre m olyarov - on top buccal tubercle, y molars - on top medialno- buccal Bug pka. In carious teeth research is conducted not only standard products, but also from several points on the bottom of the cavity, after freeing it from the softened dentin and dry. The examination of the teeth with fillings massive research carried out also from the side seals and shapes of teeth and oral surfaces of the mound - in the frontal teeth. For greater reliability also need to examine adjacent and symmetrical teeth. When caries may reduce excitability threshold of 10-20 microamps (from the bottom of cavity). With limited pulpitis - 25-30 mA; diffuse - 40-50 mA; chronic - 50-60 mA, gangrenous - 80-90 mA. When complete destruction pulp feeling "push" occurs when a current of more than 100 microamps (research carried out by placing the electrode above the mouth of the root canal). Algorithm execution 1. Plant a patient in the dental chair 2. Familiarization with the patient's dental card. 3. To collect anamnesis: - what worries - which have comorbidities 4. Wash hands, wear gloves5. Explain to the patient the essence of manipulation that will be carried out 6. The device OCM-50 to connect to the mains: - Press "10" - Press the power button , give the machine to warm up 5 minutes - Press the "D" for installation of the device pool. - passive electrode, preliminary no preservative-treated (p -n Bacilol) give the

patient's hand by placing a thumb on the button - tooth that is examined, impose cotton rolls and dried - Sterile active electrode is placed on the sensing point of the tooth - patient presses the button, and holds it until the first sensation in the tooth. Device records the last current pulse of magnitude - Measurement is performed three times, and outputting the median - If the tooth does not respond to a range of 10 microamps should go to the next range ( "50" or "150") and carry out repeated research - before the next inspection must press "On"Mistakes and complications 1. unscrupulous held medical history may cause disturbances in patients' health. 2. Ignoring not contraindications for adherence technique of E OD affords biased parameters and incorrect diagnosis. Differential diagnostic signs of chronic gangrenous pulpitis and chronic apical periodontitis 

          

Dif Ferenczi cial I di agnostic g angrenoznogo pulpitis and chronic apical periodontitis

sign Diagnosisgangrenous pulpitis Chronic

in erhushechny periodontitisThe nature of pain Missing or

aching, arises from exposure to hot

No, perhaps a feeling of discomfort and biting while I'm on the tooth

sounding Very painful in the mouth of the channel or in its depth

painless

electric pulp test 40-80 microamps 100-120 microamps  

 10. Materials for self-mastery of knowledge and skills provided by this work. 10.1 Use the test at different levels from the cathedral test bank. 

11.Tema next session. " Ency- mennye treatment technology pulpit in and periodontitis. Physical factors in the treatment of complicated caries "