Diagnosis and treatment planning

Diagnosis: Diagnosis is the science of recognizing 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 Review o Subjective History o Objective Testing o Analysis of data collected Clinical diagnosis o Plan of Action Medical history review: o Review/update written medical questionnaire o Medications o Allergies, e.g. in case of latex allergy: Non-latex rubber dam should be used Latex-free gloves should be worn One report of allergy to gutta-percha no definitive proof that a true allergic reaction occurred Consult patients allergist o Need for SBE 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 for early morning Ensure that patient has had morning insulin and breakfast Have a source of sugar readily available o Pregnancy o 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) diagnosis o Determines urgency of treatment o 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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Extraoral sinus tracts associated with necrotic teeth

A sinus tract should be traced with a Gutta Percha cone

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

Discoloration

Characteristic Jshaped or halo lesion associated with fractured root

o 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

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Tooth Slooth used to assess cracked teeth and incomplete cuspal fractures

o Palpation Test: Extraoral To detect swollen or tender lymph 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 and contralateral teeth There are many causes of mobility besides pulpal inflammation extending into the PDL o 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

Endo Ice

Ice Stick

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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: + or sensitivity 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 usually tests 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 cavity o 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: 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 (stimulated pain) 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 Responds Pain that lingers Periapical tests Generally not tender to percussion or palpation Necrosis: Symptoms No thermal sensitivity Radiograph Dependent on periapical status Pulp tests No response Periapical tests Dependent on periapical status Previous endodontic treatment

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o Possible periradicular diagnosis: Normal periapical tissue: 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 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: 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

Acute apical abscess

Incision & Drainage

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
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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

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