diagnosis and treatment planning
TRANSCRIPT
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Diagnosis and Treatment Planning
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Definition
Diagnosis is the determination of the nature of a diseased condition by careful investigation of its symptoms and history
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Sequence of Events
Medical History Review Subjective History Objective Testing Analysis of data collected – Clinical diagnosis Plan of Action
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Medical History Review
Review/update written medical questionnaire Medications Allergies Need for SBE prophylaxis Diabetes Pregnancy Written consultation with physician as required
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Medical History Review
SBE Prophylaxis Required for endodontic treatment in at risk
patients AHA recommendations should be followed
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Medical History Review
Prescribe:2 grams Amoxicillin 1 hour prior to treatmentClindamycin 600 mg for penicillin allergic
patients
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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
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Medical History Review
PregnancyAvoid treatment in first and third
trimestersKeep radiographic exposure to a
minimum
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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
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Medical History Review
The only systemic contraindications to endodontic therapy are:
Uncontrolled diabetesA very recent myocardial infarct
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Subjective History
Chief complaintIn patient’s own words
“My tooth hurts when I chew hard foods” “I can’t drink cold soda”
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Pain History
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Subjective History
Pain HistoryLocation Intensity DurationStimulusReliefSpontaneity
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Pulpal Pain
Very poorly localized IntermittentThrobbing Intensified by heat, cold and sometimes
chewing May be relieved by coldUsually severe
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Pulpal Pain
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Periradicular Pain
May be well localizedDeep painIntensified by chewingModerate to severe in intensity
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Periodontal Pain
May be well localizedIntensified by chewingModerate to severe in intensity
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Periradicular /Periodontal Pain
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Subjective History
Gives rise to tentative diagnosisDetermines urgency of treatmentConfirmed by examination and special tests
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Objective Testing
Visual ExaminationRadiographsPercussion PalpationMobilityThermal tests
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Objective Testing
Electric Pulp TestPeriodontal probingSelective anesthesiaTest cavityTransilluminationOcclusion
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Visual Examination
Extra-oral examinationFacial asymmetrySwellingExtra oral sinus tractTMJ
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Extra-oral Swelling
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Visual Examination
Extra oral sinus tracts associated with necrotic teeth
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Visual Examination
Intra-oral examinationSoft tissue lesions
SwellingRednessSinus tract
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Acute apical abscess
Acute apical abscess Incision and drainage
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Visual Examination
A sinus tract should be traced with a gutta-percha cone
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Visual Examination
Hard tissuesCariesLarge or defective restorationsDiscolored/chipped teeth
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Discoloration
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Radiographs
Always take your own pre-operative radiograph
Never make a diagnosis based on radiographic evidence alone
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Radiographs
Consider taking a bitewing film of posterior teeth
Note characteristic appearance of fractured root
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Radiographs
Characteristic J-shaped or halo lesion associated with fractured root
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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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Percussion Test
Vertical percussion Horizontal percussion
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Percussion Test
Tooth Slooth
Used to assess cracked teeth and incomplete cuspal fractures
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Palpation Test
ExtraoralTo detect swollen or tender lymph nodes
IntraoralMay detect early periapical tenderness Identifies soft tissue swellingMust compare with other areas
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Palpation
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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
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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
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Thermal Tests
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Thermal Tests
Ice stick
CO2 Snow
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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
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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)
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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
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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
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Electric Pulp Test
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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
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Electric Pulp Testing
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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
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Periodontal Examination
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Periodontal Examination
An isolated deep pocket may indicate a root fracture
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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
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Test Cavity
Initiation of cavity preparation without anesthesia
Test of last resort
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Transillumination
Helps to identify vertical crown fractureProduces light and dark shadows at
fracture site
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Transillumination
A crack will block and reflect the light when transilluminated
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Occlusion
Hyperocclusion – a possible cause of percussion sensitivity
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Analysis
Analyze the data gathered via:HistoryExaminationSpecial tests
Arrive at a clinical (not histologic) diagnosis:Pulpal diagnosisPeriapical diagnosis
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Possible Pulpal Diagnoses
NormalReversible pulpitisIrreversible pulpitisNecrosisPrevious endodontic treatment
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Normal Pulp
Symptoms None Radiograph No periapical change Pulp tests Responds normally Periapical tests Not tender to percussion or
palpation
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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
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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
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Necrotic Pulp
Symptoms No thermal sensitivity Radiograph Dependent on
periapical status Pulp tests No response Periapical tests Dependent on
periapical status
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Possible Periapical Diagnoses
Normal Acute apical periodontitis Chronic apical periodontitis Chronic apical periodontitis with symptoms Acute apical abscess Chronic apical abscess Condensing osteitis
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Normal Periapex
Symptoms None Radiograph No periapical change Pulp tests Responds normally Periapical tests Not tender to
percussion or palpation
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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
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Chronic Apical Periodontitis
Symptoms None Radiograph Periapical radiolucency Pulp tests No response Periapical tests Not tender to
percussion or palpation
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Chronic Apical Periodontitis with symptoms
Symptoms Pain on pressure Radiograph Periapical radiolucency Pulp tests No response Periapical tests Tender to percussion
and/or palpation
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Acute Apical Abscess
Symptoms Swelling and severe pain Radiograph +/- periapical radiolucency Pulp tests No response Periapical tests Tender to percussion and
palpation
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Chronic apical abscess
Symptoms Draining sinus – usually no pain Radiograph Periapical radiolucency Pulp tests No response Periapical tests Not tender to percussion or
palpation
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Condensing Osteitis
Symptoms Variable Radiograph Increased bone density Pulp tests Dependent on pulp
status Periapical tests +/- tenderness to
percussion and palpation
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Treatment Planning
Treatment decisions are based on:Pulpal diagnosisPeriapical diagnosisRestorability of toothPeriodontal considerationsDifficulty of caseFinancial considerations
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Treatment Planning
Two major decisions:Is root canal therapy indicated?Should I carry out this treatment
myself or should I refer the case?
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Factors that add risk to Endodontic Cases
Patient considerationsObjective clinical findingsAdditional conditions
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Patient Considerations
Medical history Local anesthetic considerations Personal factors and general considerations
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Objective Clinical Findings
DiagnosisRadiographic findingsPulpal spaceRoot morphologyApical morphologyMalpositioned teeth
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Additional Conditions
Restorability Existing restoration Fractured tooth Resorptions Endo-perio lesions Trauma Previous endodontic treatment Perforations
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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
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AAE Case Difficulty Assessment Form
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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
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Presenting complaint
“ I had a crown placed about 6 years ago and now but I have a blister over that tooth”
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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
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Medical History
Allergy to penicillinAspirin upsets pt’s stomach
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Subjective history
No subjective symptomsPt reports presence of ‘blister’ on gum
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Examination
Extra-oral examinationNo facial asymmetryNo cervical lymphadenopathyNo muscle or joint tenderness
Intra-oral examinationSinus present buccal to #14
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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
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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
49
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Pre-operative film
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Diagnosis
Pulpal necrosisChronic apical abscessRCT and restorationMedical history does not affect treatment
plan
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Access and Working length
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Completed RCT
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Summary
Pulpal Diagnoses Normal Reversible pulpitis Irreversible pulpitis Necrosis
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Summary
Periapical DiagnosesNormalAcute periradicular periodontitisChronic periradicular periodontitisAcute apical abscessChronic apical abscessCondensing osteitis
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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
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Summary
Treatment PlanningRoot canal therapy is indicated in
situations in which the pulp cannot recover: Irreversible pulpitisPulpal necrosis
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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