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Medical History B. Retamozo DDS, MSD Department of Endodontics › Endodontic diagnostic testing should be performed on all patients in which endodontic treatment is anticipated › Diagnosis is done before administering anesthetic › Duplicate symptoms by performing clinical exam and vitality tests › Develop a pulpal and a periapical diagnosis › Assemble facts – Chief complaint – Medical history – Dental history – History of the present condition – Objective exam › Interpret the clues › Differential diagnosis › Final diagnosis › The history of the symptoms stated in the patient’s own words. › Can the patient point to where they think the pain is? – Can the patient reproduce symptoms by pressing on tooth? › Majority of patients are older with complex medical problems › Antibiotic premedication requirement › Are they on any pain medications? › Conditions that may present as tooth pain – Sinusitis – Clenching, bruxing – Angina › Bisphosphonates › How long? › How much has it been bothering patient? – Any medications? › Does any specific activity precipitate painful episode? – Chewing › Prevent sleep? › Recent dental work – – – – Cleaning Fillings Crowns Root Canal Therapy › Recent trauma › Soft tissue – Pain to palpation – Swelling – Sinus tract – Lymph node enlargement › Dentition – Caries – Discolorations – Fractures – Abrasions Acute Initial Tissue damage Fast Process Painful Response Chronic Long term tissue damage Slow process Lower Response › Use adjacent teeth › Localize within an arch › Use contra-lateral teeth › You are assessing the patient’s response to a stimulus › Vitality Tests – Rely on the stimulation of Aδ fibers – Pain is caused by vital pulp tissue › Thermal – Test multiple teeth – Inexpensive – Cold › -70°C elicits pain in acute pulpitis – Heated Gutta percha › Electric pulp test – Small electrical charge that gradually increases – Only tells you if pulp is vital › Good for calcified teeth › Can’t be used for crowned teeth – False positives › Nerve fibers in the periodontium › Partially necrotic teeth with multiple roots › Necrotic pulp indicators – Swelling – Drainage › Tracking with gutta percha Normal Pulp Reversible Pulpitis Irreversible Pulpitis Necrotic Pulp › Percussion › Biting pressure › Palpation › Response indicates the involvement of the PDL – Degree of response is directly proportional to the degree of inflammation – Chronic periapical inflammation is often negative Sw elli ng Symptomatic Apical Periodontitis Acute Apical Abscess Swelling Drainage Sinus Tract Asymptomatic Apical Periodontitis Chronic Apical Abscess › Radiolucencies › Caries – Restorability › Radiolucencies › Caries – Restorability › Periodontal disease › Necessary for determining pulpal anatomy prior to access › Mobility – Indicates the integrity of the attachment apparatus › PPD’s › Tooth Slooth › Transillumination › One piece of the puzzle won’t lead to a correct diagnosis › All the data must be considered as a whole to get a clear picture of the problem › Normal › Reversible Pulpitis › Irreversible Pulpitis › Necrotic › Previously initiated › Previously treated › Normal Pulp – Responds to cold, but no pain – Responds to EPT › Reversible Pulpitis – Exaggerated response to cold, but pain does not linger – Responds to EPT – Sensitive to Sweets › Irreversible Pulpitis – – – – Pain to cold that lingers May or may not have pain to heat Spontaneous intermittent pain Constant pain › Necrotic Pulp – – – – No cold response, it may relieve pain May or may not have heat response No response to EPT Spontaneous, intermittent or constant pain › Normal › Symptomatic Apical Periodontitis › Asymptomatic Apical Periodontitis › Acute Apical Abscess › Chronic Apical Abscess › Pulpal Dx: – Irreversible Pulpitis › Apical Dx: – Symptomatic apical Periodontitis › Plan: RCT Tooth # Cold Hot Percussion EPT PPD’s 29 + - - 23 WNL 30 +++ - + 21 WNL 31 + - - 32 WNL › Pulpal Dx: – Necrotic › Apical Dx: – Symptomatic apical Abscess › Plan: RCT Tooth # Cold Hot Percussion EPT PPD’s 18 - - +++ N/A WNL 19 N/A N/A N/A N/A N/A 20 + - - N/A WNL Large buccal swelling present#18 13 Month Follow-up
