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Diagnosis and treatment planning

Diagnosis: Diagnosis is the science ofrecognizing disease by means of signs, symptoms, and tests.

Often, diagnosis is straightforward; sometimes it is not

Diagnosis is the key to start the Endodontic procedure No diagnosis No key No treatment The basic steps in the diagnostic process are as follows:

1. Chief complaint

2. History: medical and dental

3. Oral examination

4. Data analysis differential diagnosis

5. Treatment plan

Sequence of events to reach diagnosis:o Medical History Reviewo Subjective Historyo Objective Testingo Analysis of data collectedClinical diagnosiso Plan of Action

Medical history review:o Review/update written medical questionnaireo Medicationso Allergies, e.g. in case oflatex allergy:

Non-latex rubber dam should be used Latex-free gloves should be worn One report of allergy to gutta-perchano definitive

proof that a true allergic reaction occurred

Consult patients allergisto Need forSBE prophylaxis

SBE = Sub-acute Bacterial Endocarditis Antibiotic prophylaxis is needed in patients at high risk of developing infective endocarditis,

such as:

Patients with prosthetic cardiac valves Patients with previous infective endocarditis Patients with congenital heart disease

o Diabetes Do not treat uncontrolled diabetics Schedule appointment forearly morning Ensure that patient has had morning insulin and breakfast Have a source of sugar readily available

o Pregnancyo Written consultation with physician as required

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** The only systemic contraindications to endodontic therapy are:

Uncontrolled diabetes A very recent myocardial infarction

Subjective history:o Chief complaint:

Should be written in patients own words (non-technical language)My tooth hurts when I chew hard foods I cant drink cold soda

Pain History: Location Intensity Duration Stimulus Relief Spontaneity

Pulpal Pain: Very poorly localized pain

Intermittent Throbbing Intensified by heat, cold and sometimes chewing May be relieved by cold Usually severe

Periradicular/periodontal pain: May be well localized pain Deep pain

Intensified by chewing Moderate to severe in intensity

o Gives rise to tentative (provisional) diagnosiso Determines urgency of treatmento Confirmed by examination and special tests

Objective testing:o Visual Examination:

Extra-oral examination Facial asymmetry Swelling Extra oral sinus tract TMJ

Intra-oral examination Soft tissue lesions

Swelling Redness Sinus tract

Extraoral swelling

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Hard tissues Caries Large or defective restorations Discolored/chipped teeth

o Radiographs: Always take your own pre-operative radiograph Never make a diagnosis based on radiographic

evidence alone

o Percussion Test: A very significant test Always compare suspect tooth with

adjacent and contralateral teeth

Tenderness indicates inflammation inthe PDL

Cause of inflammation may be pulpal orperiodontal

Extraoral sinus tracts associated with necrotic teeth

A sinus tract should be

traced with a Gutta

Percha cone

Discoloration

Characteristic J-

shaped or halo

lesion associated

with fractured

root

Vertical PercussionHorizontal Percussion

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o Palpation Test: Extraoral

To detect swollen or tenderlymph nodes

Intraoral May detect early periapical

tenderness

Identifies soft tissue swelling Must compare with other areas

o Mobility: Reflects the extent of inflammation

in the PDL

Compare with adjacent andcontralateral teeth

There are many causes of mobility besides pulpal inflammation extending into the PDLo Thermal Test:

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

Tooth Slooth used to

assess cracked teeth

and incomplete

cuspal fractures

Endo IceIce Stick

CO2 Snow

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Isolate area with cotton rolls Dry teeth to be tested When performing a cold test, ask patient to:

Raise hand on feeling cold

Lower hand when cold feeling goes away Record:

+ orsensitivity to cold Time until cold sensitivity was felt Time that cold sensitivity lingered

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)

o 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 usuallytests vital

False positives and false negatives may occur False positive reading:

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

False negative reading: Patient is heavily pre-medicated Inadequate contact between electrode and

enamel

Recently traumatized tooth Recently erupted tooth with open apex Partial necrosis

o Periodontal probing:

An isolated deep

pocket may indicate

a root fracture

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o Selective anesthesia: May help to identify the possible source of pain An Inferior Dental Nerve block can localize pain to one

arch

Ability to anesthetize a single tooth has been questioned

o Test cavityo Transillumination:

Helps to identify vertical crown fracture A crack will block and reflect the light when

transilluminated

o Occlusion Analysis:

o Analyze the data gathered via: History Examination Special tests

o Arrive at a clinical (not histological) diagnosis: Pulpal diagnosis Periapical diagnosis

o Possible pulpal diagnosis: Normal pulp:

SymptomsNone RadiographNo periapical change Pulp testsResponds normally Periapical testsNot tender to percussion or palpation

Reversible pulpitis: SymptomsMay havethermal sensitivity (stimulated pain) RadiographNo periapical change Pulp testsResponds sensitivity not lingering Periapical testsNot tender to percussion or palpation

Irreversible pulpitis: SymptomsMay have spontaneous pain RadiographNo periapical change Pulp TestsResponds Pain that lingers Periapical testsGenerally not tender to percussion or palpation

Necrosis: SymptomsNo thermal sensitivity RadiographDependent on periapical status Pulp testsNo response Periapical testsDependent on periapical status

Previous endodontic treatment

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o Possible periradicular diagnosis: Normal periapical tissue:

SymptomsNone RadiographNo periapical change

Pulp tests

Responds normally Periapical testsNot tender to percussion or palpation

Acute apical periodontitis: SymptomsPain on pressure RadiographNo periapical change Pulp tests+/- depending on pulp status Periapical testsTender to percussion and/or palpation

** High restorations, traumatic occlusion, orthodontic treatment, cracked teeth, vertical

root fractures, periodontal disease and maxillary sinusitis may also produce this response

Chronic apical periodontitis: SymptomsNone RadiographPeriapical radiolucency Pulp testsNo response Periapical testsNot tender to percussion or palpation

Chronic apical periodontitis with symptoms: SymptomsPain on pressure RadiographPeriapical radiolucency Pulp testsNo response Periapical testsTender to percussion and/or palpation

Acute apical abscess: SymptomsSwelling and severe pain Radiograph+/- periapical radiolucency Pulp testsNo response Periapical testsTender to percussion and palpation

Chronic apical abscess: SymptomsDraining sinususually no pain RadiographPeriapical radiolucency Pulp testsNo response Periapical testsNot tender to percussion or palpation

Condensing osteitis

Acute

apicalabscess

Incision

&

Drainage

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** To all intents and purposes a diagnosis of acute or chronic apical periodontitis, acute or

chronic apical abscess and condensing osteitis are associated with pulpal necrosis

Treatment planning:o Treatment decisions are based on:

Pulpal diagnosis Periapical diagnosis Restorability of tooth Periodontal considerations Difficulty of case Financial considerations

o Two major decisions: Is root canal therapy indicated? Should I carry out this treatment myself or should I refer the case?

o Factors that add risk to endodontic cases: Patient considerations

Medical history Local anesthetic considerations Personal factors and general considerations

Objective clinical findings Diagnosis Radiographic findings Pulpal space Root morphology Apical morphology Mal-positioned teeth

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

o Root canal therapy is indicated in situations in which the pulp cannot recover: Irreversible pulpitis Pulpal necrosis

o Following root canal therapy: Posterior teeth must be restored with a crown. A post may be required if there is insufficient tooth structure to retain a core Anterior teeth may not require a full coverage restoration