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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
49
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