Diagnosis and Treatment Planning

Definition

Diagnosis is the determination of the nature of a diseased condition by careful investigation of its symptoms and history

Sequence of Events

Medical History Review Subjective History Objective Testing Analysis of data collected – Clinical diagnosis Plan of Action

Medical History Review

Review/update written medical questionnaire Medications Allergies Need for SBE prophylaxis Diabetes Pregnancy Written consultation with physician as required

Medical History Review

SBE Prophylaxis Required for endodontic treatment in at risk

patients AHA recommendations should be followed

Medical History Review

Prescribe:2 grams Amoxicillin 1 hour prior to treatmentClindamycin 600 mg for penicillin allergic

patients

Medical History Review

Diabetes Do not treat uncontrolled diabetics Schedule appointment for early morning Ensure that patient has had morning

insulin and breakfast Have a source of sugar readily available

Medical History Review

PregnancyAvoid treatment in first and third

trimestersKeep radiographic exposure to a

minimum

Medical History Review

Latex Allergy Non-latex rubber dam Latex-free gloves One report of allergy to gutta-percha – no definitive

proof that a true allergic reaction occurred Consult patient’s allergist

Medical History Review

The only systemic contraindications to endodontic therapy are:

Uncontrolled diabetesA very recent myocardial infarct

Subjective History

Chief complaintIn patient’s own words

“My tooth hurts when I chew hard foods” “I can’t drink cold soda”

Pain History

Subjective History

Pain HistoryLocation Intensity DurationStimulusReliefSpontaneity

Pulpal Pain

Very poorly localized IntermittentThrobbing Intensified by heat, cold and sometimes

chewing May be relieved by coldUsually severe

Pulpal Pain

Periradicular Pain

May be well localizedDeep painIntensified by chewingModerate to severe in intensity

Periodontal Pain

May be well localizedIntensified by chewingModerate to severe in intensity

Periradicular /Periodontal Pain

Subjective History

Gives rise to tentative diagnosisDetermines urgency of treatmentConfirmed by examination and special tests

Objective Testing

Visual ExaminationRadiographsPercussion PalpationMobilityThermal tests

Objective Testing

Electric Pulp TestPeriodontal probingSelective anesthesiaTest cavityTransilluminationOcclusion

Visual Examination

Extra-oral examinationFacial asymmetrySwellingExtra oral sinus tractTMJ

Extra-oral Swelling

Visual Examination

Extra oral sinus tracts associated with necrotic teeth

Visual Examination

Intra-oral examinationSoft tissue lesions

SwellingRednessSinus tract

Acute apical abscess

Acute apical abscess Incision and drainage

Visual Examination

A sinus tract should be traced with a gutta-percha cone

Visual Examination

Hard tissuesCariesLarge or defective restorationsDiscolored/chipped teeth

Discoloration

Radiographs

Always take your own pre-operative radiograph

Never make a diagnosis based on radiographic evidence alone

Radiographs

Consider taking a bitewing film of posterior teeth

Note characteristic appearance of fractured root

Radiographs

Characteristic J-shaped or halo lesion associated with fractured root

Percussion Test

A very significant test Always compare suspect tooth with adjacent

and contralateral teeth Tenderness indicates inflammation in the PDL Cause of inflammation may be pulpal or

periodontal

Percussion Test

Vertical percussion Horizontal percussion

Percussion Test

Tooth Slooth

Used to assess cracked teeth and incomplete cuspal fractures

Palpation Test

ExtraoralTo detect swollen or tender lymph nodes

IntraoralMay detect early periapical tenderness Identifies soft tissue swellingMust compare with other areas

Palpation

Mobility

Reflects the extent of inflammation in the PDL Compare with adjacent and contralateral teeth There are many causes of mobility besides

pulpal inflammation extending into the PDL

Thermal Tests

Cold always used Heat rarely used Compare reaction with adjacent and

contralateral teeth Refractory period of at least 10 minutes

before pulp can be retested accurately

Thermal Tests

Thermal Tests

Ice stick

CO2 Snow

Thermal Tests

Isolate area with cotton rolls Dry teeth to be tested Ask patient to:

“Raise hand on feeling cold” “Lower hand when cold feeling goes away”

Record: + or – sensitivity to cold Time until cold sensitivity was felt Time that cold sensitivity lingered

Thermal Tests

Classic Responses to Thermal (cold) Testing: Normal Pulp: Moderate transient pain Reversible Pulpitis: Sharp pain; subsides quickly Irreversible pulpitis: Pain lingers Necrosis: No response(Note false positive and false negative responses common)

Electric Pulp Test

A direct test of nerve elements of pulpal tissue

Vitality versus non-vitality only – not whether vital pulp is normal or inflamed

In multi-rooted teeth, where one canal is vital – tooth usually tests vital

False positives and false negatives may occur

Electric Pulp Test

False positive reading: Electrode contact with metal restoration or gingiva Patient anxiety Liquefaction necrosis Failure to isolate and dry teeth prior to testing

Electric Pulp Test

Electric Pulp Test

False negative reading: Patient is heavily premedicated Inadequate contact between electrode and enamel Recently traumatized tooth Recently erupted tooth with open apex Partial necrosis

Electric Pulp Testing

Periodontal Examination

Periodontal probing pocket depths must be measured and recorded

A significant pocket, in the absence of periodontal disease may indicate root fracture

Poor periodontal prognosis may be a contraindication to root canal therapy

Periodontal Examination

Periodontal Examination

An isolated deep pocket may indicate a root fracture

Selective Anesthesia

May help to identify the possible source of pain

An IDN block can localize pain to one arch

Ability to anesthetize a single tooth has been questioned

Test Cavity

Initiation of cavity preparation without anesthesia

Test of last resort

Transillumination

Helps to identify vertical crown fractureProduces light and dark shadows at

fracture site

Transillumination

A crack will block and reflect the light when transilluminated

Occlusion

Hyperocclusion – a possible cause of percussion sensitivity

Analysis

Analyze the data gathered via:HistoryExaminationSpecial tests

Arrive at a clinical (not histologic) diagnosis:Pulpal diagnosisPeriapical diagnosis

Possible Pulpal Diagnoses

NormalReversible pulpitisIrreversible pulpitisNecrosisPrevious endodontic treatment

Normal Pulp

Symptoms None Radiograph No periapical change Pulp tests Responds normally Periapical tests Not tender to percussion or

palpation

Reversible Pulpitis

Symptoms May have thermal sensitivity Radiograph No periapical change Pulp tests Responds – sensitivity not

lingering Periapical tests Not tender to percussion or

palpation

Irreversible Pulpitis

Symptoms May have spontaneous pain Radiograph No periapical change Pulp Tests Pain that lingers Periapical tests Generally not tender to

percussion or palpation

Necrotic Pulp

Symptoms No thermal sensitivity Radiograph Dependent on

periapical status Pulp tests No response Periapical tests Dependent on

periapical status

Possible Periapical Diagnoses

Normal Acute apical periodontitis Chronic apical periodontitis Chronic apical periodontitis with symptoms Acute apical abscess Chronic apical abscess Condensing osteitis

Normal Periapex

Symptoms None Radiograph No periapical change Pulp tests Responds normally Periapical tests Not tender to

percussion or palpation

Acute Apical Periodontitis

Symptoms Pain on pressure Radiograph No periapical change Pulp tests +/- depending on pulp

status Periapical tests Tender to percussion

and/or palpationHigh restorations, traumatic occlusion, orthodontic treatment, cracked teeth, vertical root fractures, periodontal disease and maxillary sinusitis may also produce this response

Chronic Apical Periodontitis

Symptoms None Radiograph Periapical radiolucency Pulp tests No response Periapical tests Not tender to

percussion or palpation

Chronic Apical Periodontitis with symptoms

Symptoms Pain on pressure Radiograph Periapical radiolucency Pulp tests No response Periapical tests Tender to percussion

and/or palpation

Acute Apical Abscess

Symptoms Swelling and severe pain Radiograph +/- periapical radiolucency Pulp tests No response Periapical tests Tender to percussion and

palpation

Chronic apical abscess

Symptoms Draining sinus – usually no pain Radiograph Periapical radiolucency Pulp tests No response Periapical tests Not tender to percussion or

palpation

Condensing Osteitis

Symptoms Variable Radiograph Increased bone density Pulp tests Dependent on pulp

status Periapical tests +/- tenderness to

percussion and palpation

Treatment Planning

Treatment decisions are based on:Pulpal diagnosisPeriapical diagnosisRestorability of toothPeriodontal considerationsDifficulty of caseFinancial considerations

Treatment Planning

Two major decisions:Is root canal therapy indicated?Should I carry out this treatment

myself or should I refer the case?

Factors that add risk to Endodontic Cases

Patient considerationsObjective clinical findingsAdditional conditions

Patient Considerations

Medical history Local anesthetic considerations Personal factors and general considerations

Objective Clinical Findings

DiagnosisRadiographic findingsPulpal spaceRoot morphologyApical morphologyMalpositioned teeth

Additional Conditions

Restorability Existing restoration Fractured tooth Resorptions Endo-perio lesions Trauma Previous endodontic treatment Perforations

AAE Case Difficulty Assessment Form

Rate the risk presented by each factor as:Average – 1High – 2Extreme – 3

A case with all average ratings should be fairly straightforward

AAE Case Difficulty Assessment Form

AAE Case Difficulty Assessment Form

If one or more factors present high or extreme risk, one must plan how to manage this extra risk prior to initiating treatment

Presenting complaint

“ I had a crown placed about 6 years ago and now but I have a blister over that tooth”

Dental History/History of presenting complaint

The patient reports no pain at any stage. She first noted the “blister” over tooth #14 about two weeks ago

Medical History

Allergy to penicillinAspirin upsets pt’s stomach

Subjective history

No subjective symptomsPt reports presence of ‘blister’ on gum

Examination

Extra-oral examinationNo facial asymmetryNo cervical lymphadenopathyNo muscle or joint tenderness

Intra-oral examinationSinus present buccal to #14

Special tests

Tooth #14 not tender on palpation Pus can be expressed from sinus tract No abnormal mobility Periodontal probing 6 mm on DP; in the

4 – 5 mm range elsewhere

Special tests

Tooth # 13 14 15 3

Percussion

Negative Negative Negative Negative

Thermal Normal No response

Normal Normal

EPT 56 No response

Not possible to test

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Pre-operative film

Diagnosis

Pulpal necrosisChronic apical abscessRCT and restorationMedical history does not affect treatment

plan

Access and Working length

Completed RCT

Summary

Pulpal Diagnoses Normal Reversible pulpitis Irreversible pulpitis Necrosis

Summary

Periapical DiagnosesNormalAcute periradicular periodontitisChronic periradicular periodontitisAcute apical abscessChronic apical abscessCondensing osteitis

Summary

To all intents and purposes a diagnosis of acute or chronic apical periodontits, acute or chronic apical abscess and

condensing osteitis are associated with pulpal necrosis

Summary

Treatment PlanningRoot canal therapy is indicated in

situations in which the pulp cannot recover: Irreversible pulpitisPulpal necrosis

Summary

Following root canal therapyPosterior teeth must be restored with a

crown. A post may be required if there is

insufficient tooth structure to retain a coreAnterior teeth may not require a full

coverage restoration