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Endodontic Assessmentsin a Differential Diagnosis
The Endodontic-Restorative Continuum
Alan H. Gluskin DDSAlan H. Gluskin DDSProfessor and ChairProfessor and Chair
Department of EndodonticsDepartment of Endodontics
The Role of Endodontic Vitality Testing
in aDifferential Diagnosis
Endodontic Differential DiagnosisMedical / DentalMedical / Dental
Extraoral ExaminationExtraoral Examination
Intraoral ExaminationIntraoral Examination
Tactile ExamTactile Exam
Definitive DiagnosisDefinitive Diagnosis
Vitality TestsVitality Tests
RadiographsRadiographs
Extraoral Visual Examinations
Facial Facial Asymmetry Asymmetry
??Yes / NoYes / No
Aggressive Aggressive SwellingSwelling
??Yes / NoYes / No
Facial Facial InjuriesInjuries
??Yes / NoYes / No
Purulent Purulent DrainageDrainage
??Yes / NoYes / No
Intraoral Visual Examination
PalpationPalpation
RadiographsRadiographs
ProbingsProbings PercussionPercussionMobilityMobility
Palpation / Digital ExaminationPalpation ExaminationPalpation Examination
Light Digital PressureLight Digital Pressure
Soft TissuesSoft Tissues
LocationLocation
Indurated, Swollen Indurated, Swollen FluctuantFluctuant
Pain IntensityPain Intensity
No Pain, Tender, No Pain, Tender, Acute PainAcute Pain
Intraoral Visual Examination
OopsOops
Endodontic Assessmentsin a Differential Diagnosis
The Endodontic-Restorative Continuum
Alan H. Gluskin DDSAlan H. Gluskin DDSProfessor and ChairProfessor and Chair
Department of EndodonticsDepartment of Endodontics
Vitality Assessment & Tools
Thermal Thermal Cold HeatCold Heat
Vital Test Vital Test CavityCavity
Electric Electric Pulp Pulp
TesterTester
Selective Selective AnesthesiaAnesthesia
Tooth Tooth Slooth™Slooth™
Fiber Fiber Optic Optic LightLight
Tentative DiagnosisTentative Diagnosis
Establish A Point of Reference
Challenge Challenge Adjacent/ Adjacent/
Contralateral Contralateral ToothTooth
Challenge Challenge Opposing Opposing Tooth or Tooth or
ArchArch
Challenge Challenge Tooth in Tooth in QuestionQuestion
Challenge Challenge QuadrantQuadrant
Vitality Assessment & Tools
Thermal Thermal Cold HeatCold Heat
Vital Test Vital Test CavityCavity
Electric Electric Pulp Pulp
TesterTester
Selective Selective AnesthesiaAnesthesia
Tooth Tooth Slooth™Slooth™
Fiber Fiber Optic Optic LightLight
RadiographsRadiographs
Tooth Responses
Hypo Hypo ResponsiveResponsive
W.N.L. W.N.L. Hyper Hyper ResponsiveResponsive
Responses Responses From ToothFrom Tooth
(-)(-) (-) / (+)(-) / (+) (+ +) , (+ + +)(+ +) , (+ + +)
MomentaryMomentary LingersLingers SpontaneousSpontaneous
Endodontic Differential DiagnosisMedical / DentalMedical / Dental
Extraoral ExaminationExtraoral Examination
Intraoral ExaminationIntraoral Examination
Tactile ExamTactile Exam
Definitive DiagnosisDefinitive Diagnosis
Vitality TestsVitality Tests
RadiographsRadiographs
Dental History - The Science
•Recognize
•Understanding
•Interpreting
Dental History - The Art
•Asking the RIGHT questions
•ACTIVE listening
Dental Emergencies
Tooth Tooth TraumaTrauma
ToothacheToothacheNon-Pulpal Non-Pulpal
InvolvementInvolvement
Tooth Tooth Knocked Knocked
OutOut
Loose Loose ToothTooth
Fractured Fractured ToothTooth
Chipped Chipped ToothToothConcussionConcussion
Diagnosing Oro-facial Pain
•Dental
•Non-Dental
Interpreting the Language of Pain
Subjective Subjective ColoringColoring AcuteAcute ChronicChronic
Low Low Grade Grade PainPain
Hx of Hx of PainPainIntenseIntenseSharpSharpSpon-Spon-
taneoustaneousDeep, Deep,
GnawingGnawing
Understanding the Language of Pain
SignsSigns SymptomsSymptoms
DentalDentalNon-DentalNon-DentalDentalDental Non-DentalNon-Dental
++
Inflammation• Cellular
• Neurologic
• Vascular
• Humoral
Language of Pulp PainDental PulpDental Pulp
Pulpal InflammationPulpal Inflammation
AsymptomaticAsymptomatic SymptomaticSymptomatic
AcuteAcute ChronicChronic
Physiology of Pulpal Pain
A-Delta A-Delta FibersFibers
PainPain
Human Human Dental PulpDental Pulp
Afferent Afferent ImpulsesImpulses
C-FibersC-Fibers
Physiology of Pulpal Pain
• A-delta Fibers:–Located in Pulp-Dentin Interface
–Myelinated–Large Diameter
A-delta Fibers – Cold / HeatThermoreceptor for Pain
•Quick
•Sharp
•Short
Physiology of Pulpal Pain
• C- Fibers:
·Located Centrally in the Pulp
·Unmyelinated
·Small Diameter
C-Fibers - HeatThermoreceptor for Pain
• Steady
• Dull / Gnawing
• Prolonged / Spontaneous
Acute Pulpal OriginAcute Pulpal Acute Pulpal PainPain
Temporary Temporary PainPain
Short Short DurationDuration
ColdCold
AbscessAbscessSpontaneousSpontaneous
ConstantConstant Pres-Pres-suresure
Swell-Swell-inging FeverFever
HeatHeat IncreaIncrea-sing-sing
Cold Cold HotHot
ThrobThrob-bing-bing
Cold Cold ReliefRelief
DiffuseDiffuse LocalizedLocalized
Chronic Pulpal OriginChronicChronicPulpal PainPulpal Pain
DullDull IntermittentIntermittent RecurrentRecurrent
DeepDeep
AcuteAcute
TolerableTolerable
AcuteAcute
AcuteAcute
AcuteAcute
Endodontic Assessmentsin a Differential Diagnosis
The Endodontic-Restorative Continuum
Alan H. Gluskin DDSAlan H. Gluskin DDSProfessor and ChairProfessor and Chair
Department of EndodonticsDepartment of Endodontics
Mobility - DepressibilityExamination
Integrity
of the
Attachment Apparatus
Tooth Mobility EvaluationMobility Mobility
ExaminationExamination
Light Lateral Light Lateral PressuresPressures
Adjacent TeethAdjacent Teeth
Suspect TeethSuspect Teeth
Class IClass I Class IIClass II Class IIIClass III
Periodontal Ligament Reaction
TraumaTrauma
Vital PulpVital PulpNecrotic Necrotic
PulpPulp
P.D.L. P.D.L. ReactionReaction
HealthyHealthy SickSickEgressing Egressing
OutOut
Perio Perio DiseaseDisease
Egressing Egressing OutOut
Thermal Responses
Cold Stimulus ChallengeCold Cold TestTest
ToothTooth
Ethyl ChlorideEthyl ChlorideRefrigerantsRefrigerants IceIce
Hyper Hyper ResponseResponse
CarbonCarbonIceIce
W.N.L.W.N.L. Hypo Hypo ResponseResponse ReliefRelief
Cold Test
Heat Challenge
Heat Stimulus ChallengeHeat Heat TestTest
ToothTooth
Warm Gutta Warm Gutta PerchaPercha
Hot Tap Hot Tap WaterWater
Hyper Hyper ResponseResponse
Rubber Disc Rubber Disc FrictionFriction
W.N.L.W.N.L. No No ResponseResponse
Delayed Delayed ResponseResponse
EarlyEarly
Pulpal InjuryPulpal Injury
Thermal Thermal ChallengeChallenge
Normal PulpNormal Pulp Inflamed Inflamed PulpPulp Aged PulpAged Pulp
LateLate
Neural Responses
Electric Response AssessmentElectric Pulp Electric Pulp
TesterTester
Adjacent ToothAdjacent Tooth
Suspect ToothSuspect Tooth
Contralateral Contralateral ToothTooth
Hyper Hyper ResponseResponse W.N.L.W.N.L. Hypo Hypo
Response Response No No
ResponseResponse
Neuron Neuron ActivityActivity
Neural Neural ResponsesResponses
Vital PulpVital Pulp Necrotic Necrotic PulpPulp
Total Total NecrosisNecrosis
Partial Partial NecrosisNecrosis
Aged Aged TissuesTissues
Trauma Trauma to Pulpto Pulp
Young Young TissuesTissues
Sensory Pathways
Identifies Identifies Source of Source of
Tooth PainTooth Pain
Sensory Sensory PathwaysPathways
Identifies Identifies Referred Referred
Pain From Pain From ToothTooth
Identifies Identifies Non - Tooth Non - Tooth
PainPain
Anesthetic DiagnosisSelective Selective
AnesthesiaAnesthesia
Ligamental Ligamental InjectionsInjections Local AnesthesiaLocal Anesthesia
Relieves Relieves Suspect Suspect
ToothTooth
Regional Regional BlocksBlocks
Reveals Reveals Referral Referral
PainPain
Reveals Reveals Trigger Trigger SitesSites
Reveals Reveals Referral Referral
PainPain
Test Cavity Challenge
Test Cavity ChallengeTest CavityTest Cavity
No Anesthetic No Anesthetic
Prepare Shallow Prepare Shallow AccessAccess
Penetrate Into Penetrate Into Dentin / ChamberDentin / Chamber
No ResponseNo Response Slight ResponseSlight Response Acute ResponseAcute Response
Pulpal NecrosisPulpal Necrosis Degenerating PulpDegenerating Pulp Vital PulpVital Pulp
100% 100% HealthyHealthy
Extent of Extent of Pulp VitalityPulp Vitality
Test CavityTest Cavity
Vital PulpVital Pulp
Endodontic Endodontic AccessAccess
NecroticNecrotic
DegeneratingDegenerating
Fractured Tooth AssessmentTooth Tooth Slooth™Slooth™
Bite & ReleaseBite & Release
Sharp PainSharp Pain
Engage Cusp TipEngage Cusp Tip
Shallow Shallow FxFx Cuspal FxCuspal Fx Vertical Vertical
FxFxHorizontal Horizontal
FxFx
No PainNo Pain
Occlusal Provocation
Occlusal Occlusal ProvocationProvocation
Vital Vital ToothTooth
Damage Damage to Crownto Crown
NecroticNecroticToothTooth
Damage Damage to Rootto Root
Damage Damage to Rootto Root
Damage Damage to Socketto Socket
Crack Detection
Tooth Slooth™Tooth Slooth™
Checking for crack/fracture
Crack MB cusp
Deep isolated pocket
Transillumination
TransilluminationFiber Optic Fiber Optic Light ExamLight Exam
Thru Cervical Thru Cervical LineLine
Light Light ConductanceConductance
Through & Through & ThroughThrough
Abrupt Abrupt StoppageStoppage
Surface Surface CrazingCrazing
Thru Line Thru Line AnglesAngles
Thru Cusps Thru Cusps TipsTips
Superficial Superficial CracksCracks
TransilluminationTransillumination
Hard Tissue Hard Tissue IntegrityIntegrity
Deep Deep FracturesFractures
Moderate Moderate CrazingCrazing
Acute Crack
MisdiagnosisMisdiagnosis
The Endodontic-Restorative Continuum
Decision Making
Diagnosis Prognosis
Treatment
Decision Making
Diagnosis Prognosis
Treatment
Host ResistanceEndo - PerioPatient Dental I.Q.Operator Limitations
How Critical is Tooth? Cost EffectivenessTreatment Alternatives Sequence of Treatment Use of Specialist
HistoryEtiologyEndo and / or Perio
Determination of Prognosis
• Periodontal Prognosis
• Endodontic Prognosis
• Restorative Prognosis
Periodontal Prognosis
• Bone loss
• Pocketing
• Health of Periodontium
Periodontal Concerns
• General periodontal status
• Isolated periodontal defect
Endodontic Prognosis
• Vitality
• Periapical area
• Canals negotiable?
• Posts present?
Endodontic Diagnosis Vital Tooth
•Reversible•Irreversible
Electric Pulp Tester
Cold Test
Cold Test
Tooth Restorability • Caries
• Chip in enamel
• Chip into dentin
• Cusp fracture
• Tooth fracture
• Root amputation
Restorative Prognosis determined by…
Structural IntegrityStructural Integrity
Treatment AlternativesRestore as is...
Restore as is... and extract
Extract–No further treatment–Fixed partial denture–Removable partial denture–Implant
and hopeand hope
Financial Considerations
•At UOP
•In Private Practice
Ferrule Effect
• What is it?
• Facial/Lingual vs Mesial/Distal
• Anterior Tooth
• Posterior Tooth
• How wide / thick?
How to achieve the ferrule
• Prep into sulcus
• Crown lengthening
• Extrusion
FerruleFerrule• 11.5 -2 mm long.5 -2 mm long
• Parallel wallsParallel walls
• Totally encircle toothTotally encircle tooth
• End on sound tooth surfaceEnd on sound tooth surface
• Not invade attachment Not invade attachment apparatusapparatus
CoreCore• Replaces missing Replaces missing
tooth structuretooth structure
• Supports rehabilitationSupports rehabilitation
Core MaterialsCore Materials
• Cast metalCast metal
• AmalgamAmalgam
• Composite resinComposite resin
• Glass Ionomer / Glass Glass Ionomer / Glass Ionomer Silver materialsIonomer Silver materials
Fractured Cusp into Furcation
Crown/restorative disassembly
Tooth isolated for endodontics
Resin syringe
Build-up matrixed
Crown lengthening
Post-op crown lengthening
Post-op crown lengthening
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