5e6dEndo Dx

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8/12/2019 5e6dEndo Dx


INTRODUCTION

Endodontic diagnosis and treatment occur intwo scenarios. The first occurs when theemergency patient presents with pain andpossibly swelling and fractured teeth. The

second scenario is part of the restorativetreatment plan when pulpal or periapicaldisease is detected but without symptoms.In both scenarios a through history andexamination leading to a diagnosis are

essential to provide appropriate andeffective care. The key to accuratetreatment is appropriate diagnosis.

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Diagnosis is the science ofrecognizing disease by means ofsigns symptoms and tests.

An accurate diagnosis is the result ofsynthesis of scientific knowledge,clinical experience, intuition andcommon sense. The process is thusboth an art and science

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1.Assemble facts

Chief complaint

Medical & Dental history Subjective sym.

History of the present condition

2. Screen & interpret the assembled clues (Oral Exam)

3. Differential Diagnosis

4. Operational or working diagnosis (Final diagnosis)

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A proper diagnosis begins with informationabout the patient’s chief complaint, alongwith the objective findings found through

clinical and radiographic examinationscoupled with appropriate pulp tests

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Pain is a subjectivesymptom and unlike an

ulcer, there may benothing visually. The

history is, therefore,paramount.

A pain is clarified

methodically by twelvequestions which may beincluded in aquestionnaire.

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PATIENT QUESTIONNARE

1. How would you describe the pain?Sharp/ Stabbing____ Dull/ Throbbing___ Are often forth coming? ___

2. Where is the pain most severe?(The patient should be asked to point to the siteof maximum intensity.)

3. Where does the pain spread to? (The patient should outline the area with afinger.)

4. How Severe is the pain???

5. Does the pain prevent you from getting to sleep or awake you up at night?

6. When did the pain start?

7. Is the pain continuous or does it come and go?

8. If it comes and goes, how long does it lasts for each time?9. Does anything cause the pain to start?

10. Does anything make the pain worse?

11. Does anything make the pain better?

12. Are there any other problem?

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Others:1. When did you first notice the symptoms?2. Did symptoms occur suddenly or gradually?3. Please check the intensity of your pain-------

LEVEL OF INTENSITY 0__1__ 2__ 3__ 4__ 5__ 6__ 7__ 8__ 9__ 10__

1. Do you grind or clench your teeth? Yes ___ No ___

2. If so, do you wear a night guard? Yes ___ No ___3. Has a restoration (filling 0r crown) been placed on this tooth recently? Yes ___ No ___

1. Prior to this appointment, has root canal therapy been started on this tooth? Yes ___ No ___

2. Any past trauma or injury to this tooth? Yes ___ No ___

3. If yes, describe past trauma and state the occurrence date.

Is there anything else we should know about your teeth, gums or sinuses that wouldassist in diagnosis?

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Chief complaint is the history of the

symptoms noted in the patient’s ownwords that describes the symptomscausing the discomfort

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SUBJECTIVE INFORMATION

History of painStimulus of pain

Frequency of painSeverity of painDuration of pain

Spontaneity of painLocation of painCharacter of pain

Alleviation of pain

OBJECTIVE INFORMATION

Visual examinationPercussion and palpation

Caries and fracturedrestorationsSinus tracts

Tooth fracturesExtensive restorationExposed dentin, wear facetsPeriodontal disease, mobility

RADIOGRAPHIC ASSESSMENT

Tooth length, no. of roots

Calcifications, orifice locationNumber of canals, radiolucenciesResorptions, fractures

COMPARATIVE TESTING

Thermal tests

Electric pulp tests Anesthetic test, test cavityTransillumination

ASSESSMENT OF PULP AND PERIRADICULAR TISSUES

PLAN OF TREATMENT

History of Present Illness

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CLINICAL EXAMINATION

VISUAL EXAMINATION:

Extra oral examination

Intra oral examinationSoft tissues:

Color

Contour Consistency

Sinus opening

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COLOR

Normal crown - life like translucency

Discolored opaque – inflamed, degenerated or necroticpulp.

Calcified Canal – Light Yellow Hue of the Crown

Pink Tooth – Indicates InternalResorption

CROWN CONTOURWear Facets, Fractures and Restorations

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Palpation

Digital pressure is usedto check fortenderness in the oral

tissues overlying thesuspected teeth.

Bimanual palpation ismost efficient to detect

incipient swellingsbefore it is clinicallyevident

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Percussion

Normal resonant sound on percussion indicates good periodontal ligament

Metallic sound on percussion indicates ankylosis.

Response to percussion not only indicates the involvementof the PDL but also the extent of the inflammation.(degreeof response directly proportional to degree ofinflammation).

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Mobility

Tooth mobility provides an indication of the integrity of theattachment apparatus.

Mobility is graded as:

Grade I – Noticeable horizontal movement in its socket.

Grade II – within 1 mm of horizontal movement.

Grade III – Horizontal movement greater than 1 mm and/orvertical depressibility.

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Radiographs are an important andnecessary adjunct in Endodontics.

Accurate radiographic techniques and

proper interpretation are essential forsound diagnosis and treatment. Radiograph techniques of endodontic

importance: Preiapical

BitewingOPG

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Role of Radiograph in Endodontics:

Endodontic diagnosis. Determination of prognosis of treatment. Disclosing the presence and extent of caries. Checking the thickness of PDL.

To see the presence or absence of lamina dura. To see the number, shape, length and internalanatomy of root canal.

To check any obstruction present within the root canal. To see the quality of the previous root canal. To see the tooth calcification.

Detrmination of working length and selection of mastercone.

Help to find endodontic errors like, perforation, ledgingand instrument seperation.

To see any resorption associated with tooth.

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Pulp Vitality Tests

Assessment of vitality using routine methodsrely on the stimulation of Aδ nerve fibersand there is no direct indication of the blood

flow.Three methods are used to stimulate the Aδ

nerve fibers

1. Thermal stimulation (Heat or Cold Test)

2. Electrical stimulation3. Direct dentin stimulation.

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Heat Test

Inexpensive

The temperature used is65.5ºC to elicit theresponse

Can use Gutta percha – (base plate gutta percha)

Cast metal crown

restorations are too thickto allow heated GP toelicit response

In such cases a rubber wheel is used to

elicit the response

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Cold Test

Various materials used for cold

test are Cones of ice – -20ºC

Ethyl chloride spray – -40ºC

Carbon- di- oxide snow–

-70ºC Application of cold for 4

seconds lowers thetemperature to between 26 and

30ºC eliciting pain. Within thepulp temperature is lowered by0.2ºC.

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Electric Pulp Test

Electrolyte applied on the teeth to transmitcurrent

Jelly used for ECG is ideal

When electrolyte contacts the tooth an electriccharge is applied by pressing rheostat button.A small charge is released initially andincreased until response is felt.

Select control teeth – contra lateral teeth andadjacent teeth.

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Interpretation

Positive (Normal)

Exaggerated, brief

Exaggerated, prolonged Negative

False positive

False negative

Inconclusive

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Only Aδ fibers are activated by electric

tests

Aδ fibers produce initial momentary sharp

response to electric stimuli because of itsperipheral location, low threshold &greater conduction velocity.

Continuous constant pain is produced bythe smaller C fiber stimulation as it isassociated with tissue damage andinflammatory process.

Physiology of pulp testing

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Battery plug in

Electrical deficiencies

Output current variations

Battery run down and not deliveringfull current

all these give variable results with EPT

Molars give readings not indicative ofthe true pulpal condition.

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Tests are not reliable on immature

teeth of young patients as these teethcontain fewer Aδ fibers than matureteeth and myelinated nerves do notreach their maximal depth ofpenetration into the pulp until the apex

completes its development.

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Laser doppler flowmetry

Pulp oximetry

Dual wavelength spectro-photometry

Plethysmography

Xenon– 133

Hughes probeye camera Gas desaturation

Electromagnetic flowmetry

Radiolabeled microsphere

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Bite test

Trans-illumination

Anesthetic test

Test Cavity

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Biting on a roll ofrubber dam material,a rubber or wood

point or dedicatedpyramidal shape,plastic instrument

may assist in thediagnosis of crackedtooth.

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A dedicated light source may bepurchased (fiber optic light).

Alternatively a composite curing lightmay be employed.

It is helpful in diagnosis of-

Tooth cracks

Inter-proximal caries

Maxillary sinusitis.

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Starting from the distal most tooth of thesuspected quadrent, intraligamentary

anesthesia is injected. If pain persists nexttooth is anesthetized (the one mesial to it).In this way the process is continued untilthe affected tooth is identified.

This is a relatively painful process. So it isperformed if all other tests a inconclusive.

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This method is performed if all othertest are inconclusive. In this method

a cavity is drilled with out applicationof anesthesia and patient is asked ifthere is any sensation of pain.

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Conclusion

A dentist can develop a number ofassets to become a successfuldiagnostician. The most important of

these are knowledge, interest,intuition, curiosity and patience. Thesuccessful diagnostician must also

have acute senses and the necessaryequipment for diagnosis.

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5e6dEndo Dx

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