Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 treatment Clindamycin 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 Pregnancy Avoid treatment in first and third trimesters Keep 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 diabetes A very recent myocardial infarct Subjective History Chief complaint In patient’s own words “My tooth hurts when I chew hard foods” “I can’t drink cold soda” Pain History Subjective History Pain History Location Intensity Duration Stimulus Relief Spontaneity Pulpal Pain Very poorly localized Intermittent Throbbing Intensified by heat, cold and sometimes chewing May be relieved by cold Usually severe Pulpal Pain Periradicular Pain May be well localized Deep pain Intensified by chewing Moderate to severe in intensity Periodontal Pain May be well localized Intensified by chewing Moderate to severe in intensity Periradicular /Periodontal Pain Subjective History Gives rise to tentative diagnosis Determines urgency of treatment Confirmed by examination and special tests Objective Testing Visual Examination Radiographs Percussion Palpation Mobility Thermal tests Objective Testing Electric Pulp Test Periodontal probing Selective anesthesia Test cavity Transillumination Occlusion Visual Examination Extra-oral Facial examination asymmetry Swelling Extra oral sinus tract TMJ Extra-oral Swelling Visual Examination Extra oral sinus tracts associated with necrotic teeth Visual Examination Intra-oral examination Soft tissue lesions Swelling Redness Sinus 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 tissues Caries Large or defective restorations Discolored/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 Extraoral To detect swollen or tender lymph nodes Intraoral May detect early periapical tenderness Identifies soft tissue swelling Must 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 CO2 Snow Ice stick 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 fracture Produces 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: History Examination Special tests Arrive at a clinical (not histologic) diagnosis: Pulpal diagnosis Periapical diagnosis Possible Pulpal Diagnoses Normal Reversible pulpitis Irreversible pulpitis Necrosis Previous endodontic treatment Normal Pulp Symptoms Radiograph Pulp tests Periapical tests None No periapical change Responds normally Not tender to percussion or palpation Reversible Pulpitis Symptoms Radiograph Pulp tests Periapical tests May have thermal sensitivity No periapical change Responds – sensitivity not lingering Not tender to percussion or palpation Irreversible Pulpitis Symptoms Radiograph Pulp Tests Periapical tests May have spontaneous pain No periapical change Pain that lingers Generally not tender to percussion or palpation Necrotic Pulp Symptoms Radiograph Pulp tests Periapical tests No thermal sensitivity Dependent on periapical status No response 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 Radiograph Pulp tests Periapical tests None No periapical change Responds normally Not tender to percussion or palpation Acute Apical Periodontitis Symptoms Radiograph Pulp tests Periapical tests Pain on pressure No periapical change +/- depending on pulp status Tender to percussion and/or palpation High restorations, traumatic occlusion, orthodontic treatment, cracked teeth, vertical root fractures, periodontal disease and maxillary sinusitis may also produce this response Chronic Apical Periodontitis Symptoms Radiograph Pulp tests Periapical tests None Periapical radiolucency No response Not tender to percussion or palpation Chronic Apical Periodontitis with symptoms Symptoms Radiograph Pulp tests Periapical tests Pain on pressure Periapical radiolucency No response Tender to percussion and/or palpation Acute Apical Abscess Symptoms Radiograph Pulp tests Periapical tests Swelling and severe pain +/- periapical radiolucency No response Tender to percussion and palpation Chronic apical abscess Symptoms Radiograph Pulp tests Periapical tests Draining sinus – usually no pain Periapical radiolucency No response Not tender to percussion or palpation Condensing Osteitis Symptoms Radiograph Pulp tests Periapical tests Variable Increased bone density Dependent on pulp status +/- tenderness to percussion and palpation Treatment Planning Treatment decisions are based on: Pulpal diagnosis Periapical diagnosis Restorability of tooth Periodontal considerations Difficulty of case Financial 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 considerations Objective clinical findings Additional conditions Patient Considerations Medical history Local anesthetic considerations Personal factors and general considerations Objective Clinical Findings Diagnosis Radiographic findings Pulpal space Root morphology Apical morphology Malpositioned 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 – 1 High – 2 Extreme – 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 penicillin Aspirin upsets pt’s stomach Subjective history No subjective symptoms Pt reports presence of ‘blister’ on gum Examination Extra-oral examination No facial asymmetry No cervical lymphadenopathy No muscle or joint tenderness Intra-oral examination Sinus 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 Percussion Negative 14 15 3 Negative Negative Negative Thermal Normal No response Normal Normal EPT 56 No response Not possible to test 49 Pre-operative film Diagnosis Pulpal necrosis Chronic apical abscess RCT and restoration Medical history does not affect treatment plan Access and Working length Completed RCT Summary Pulpal Diagnoses Normal Reversible pulpitis Irreversible pulpitis Necrosis Summary Periapical Diagnoses Normal Acute periradicular periodontitis Chronic periradicular periodontitis Acute apical abscess Chronic apical abscess Condensing 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 Planning Root canal therapy is indicated in situations in which the pulp cannot recover: Irreversible pulpitis Pulpal necrosis Summary Following root canal therapy Posterior teeth must be restored with a crown. A post may be required if there is insufficient tooth structure to retain a core Anterior teeth may not require a full coverage restoration