Download Lesson 2

Clinical Diagnostic
Procedures
Ch #4 Diagnosis & Tx Planning
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Training in Basic Science enables:
– Perform diagnostic tests
– Interpret test results differentially
– Psychologically manage patient during
testing
– Formulate diagnosis and treatment plan.
Systematic Approach to
diagnosis
1.
2.
3.
4.
5.
Ascertain chief complaint
Take relevant medical and dental
history
Conduct thorough SubjectiveObjective- Radiographic examinations
Analyze the data obtained
Formulate appropriate diagnosis
Scope of Endodontics
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Vital Pulp therapy
Nonsurgical RCT
Endo Surgery
Retreatment
Hemisection-Root
Amputation
Bleaching
Intentional
replantation
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Endodontic
Endosseous implants
Apexification
Apexogenesis
Transplantation
Treatment of trauma
Perio-endo pathosis
Ortho-endodontics
Graduating General Dentist
Should be very skilled in diagnosis and
treatment planning over a broad base
Should know when to consult and refer.
Systematic Approach to
diagnosis
1.
Ascertain chief complaint
Diagnosis
1.
Chief Complaint
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First information obtained
Problem expressed in patient’s own words
Recorded in non-technical language
If referred may be “No CC”
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© 2005 Elsevier
Diagnosis
1.
2.
Ascertain chief complaint
Take relevant medical and dental
history
2.
Health History
– Comprehensive for new patients
– Update data of prior patients
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Demographic data
Medical History
Current Medications
Dental History
Chief complaint
Present illness
Demographic data
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Identify Pt characteristics
Medical History
There are no absolute C/I to
endodontics
 Endodontics is less traumatic than
extraction
 Older patients are in need of RCT
 Cases that need precautionary
measures
 When consultations are needed
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Current Medications
List medications as presented by patient
 Review C/I and precautionary measures
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© 2005 Elsevier
Dental History
Pay attention to state of patient
 Ask probing questions
 Establish good rapport and caring
attitude.
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Diagnosis
1.
2.
3.
Ascertain chief complaint
Take relevant medical and dental
history
Conduct thorough SubjectiveObjective- Radiographic examinations
1.Subjective Examination
Present Illness
 Pain
 Tentative diagnosis
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Present Illness
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Only if a patient has a sign problem
If no sign symptoms go on to objective tests
Pain may affect pt;s psychology
Dr must be open, caring, and interested to
elicit the most info
Ask further probing questions
Reiterate to the patient what they said in a
clear manner.
Pain
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Intensity
– Intense
irreversible pathosis
– Recent, not long standing
– Unrelieved by analgesic
– Intermittent
– Irreversible pulpitis
– Acute apical periodontisits or abscess
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Spontaneous pain
– Without eliciting stimulus
– Awakens patient
– May be relieved by cold
– Usually irreversible pulpitis
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Continuous pain
– Lingering type of pain after removal of
stimulus
– Continuous pain with thermal stimulus=
irreversible pulpitis
– Continuous pain after application of
pressure = periradicular pathosis
Tentative diagnosis
Careful subjective questions
 Rule out non-odontogenic causes
 Urgency of treatment determined
 Confirmed or denied by hands-on oral
examination and clinical tests.
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2.Objective Examination
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Extraoral examination
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General appearance
skin tone
Facial asymmetry
Swelling
Discoloration
Redness
Extraoral scars
Sinus tracts
Tender or enlarged lymph nodes
Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM)
© 2005 Elsevier
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Intraoral examination
– Soft tissue:
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Lips-Oral mucosa- Cheeks- Tongue- PalateMuscles
– Alveolar mucosa & attached gingiva
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Discoloration
Inflammation
Ulceration
Sinus tract formation
– Dentition
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Discoloration
Fractures
Abrasions
Erosions
Caries
Large restorations
Clinical tests
Complex Process
 Tests of patients response!
 Presence of limitations
 May be inconclusive
 Supplementary confirmatory tests
needed
 False-neg + False-pos
 Control teeth
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Periapical tests
Percussion
 Palpation
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– Indicative of periradicular inflamation
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© 2005 Elsevier
Pulp vitality tests
Cold tests
 Direct dentin stimulation
 Heat tests
 Electric pulp testing
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© 2005 Elsevier
Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM)
© 2005 Elsevier
Periodontal Examination
Probing
 Mobility
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Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM)
© 2005 Elsevier
3.Radiographic examination
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Periapical lesions (of odontogenic
origin):
– LD is lost apically
– Angulation does not change position
– Lucency resembles a hanging drop
– Usually cause of necrosis is evident
– Condensing ostietis- enostosis
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Pulpal lesions
Special tests
Caries removal
 Selective anesthesia
 Transillumination
 Sinus tract tracing
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Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM)
© 2005 Elsevier
Diagnosis and Tx Plans
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Normal or reversible pulpitis
– Remove cause
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Irreversible pulpitis
– RCT
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Necrosis
Treatment choices
Routine cases
 Difficult Procedures
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– Complications
– Adjunctive procedures
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Prognosis
Systematic Approach to
diagnosis
1.
2.
3.
4.
Ascertain chief complaint
Take relevant medical and dental
history
Conduct thorough SubjectiveObjective- Radiographic examinations
Analyze the data obtained
Diagnosis
 Pulpal:
– Normal
– Reversible
– Irreversible
– Necrotic
– Extirpated
 Periapical
– Normal
– Acute Apical Periodontitis
– Chronic Apical
Periodontitis
– Acute Apical Abscess
– Chronic Apical Abscess
– Condensing Ostietis
Diagnosis
symptoms
radiographic
pulp tests
PA tests
Treatment
Normal
None
None
Responds
Not sensitive None (unless
intentional)
None
Reversible
Pulpitis
may or may not have
slight symptoms to
theraml stimuli
No PA changes
Responds
Not sensitive None (unless
intentional)
Remove cause
Irreversible
Pulpitis
may or may not have
slight symptoms to
thermal stimuli
may have spontaneous
or severe pain to thermal
stimuli
No PA changes
condensing ostetis
Responds
may have severe pain on
stimulus
may or may not have pain
on percussion and palpation
RCT
Pulpotomy,
pulpectomy
Extraction
Necrosis
None
PA
PA
No response
PA
RCT
Extraction
None
None
Responds
Not sensitive None (unless
intentional)
None
Pain on mastication or
pressure
None
Response
No response
Pain on percussion or
palpation
RCT
Apical radiolucency
No response
None
Mild pain on percussion
or palpation
RCT
Usually RL lesion
No response
Pain on percussion
Debridement
Draining
Pulpal
Periapical
Normal
Acute Apical
Periodontitis
Chronic apical
periodontitis
Acute Apical
Abscess
None
mild
Swelling
Significant pain
Chronic Apical
abscess
Draining sinus
Usually RL lesion
No response
None
RCT
Condensing
Osteitis
variable
Increase bone
density
Variable
Variable
Variable
Difficult diagnosis
Longitudinal fratures
 Cracked tooth
 Stressed tooth
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Treatment Planning
To treat or not to treat
 Treatment related to diagnosis
 Number of appointments
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Prognosis
Assess difficulty of case
 Refer when needed
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422 RDS
Clinical Endodontic Form
Serial No.:
__________
_________
Case No.:
Student's Name:
File No.:
Patient's Name:
Age: __________
Telephone No.:
(W)______________
_________
Exam Date:________________
Sex: ______________
Tooth No.: _______________
Chief Complaint:
DIAGN
OSTIC
TESTS
:
PAIN:
CLINICAL EXAM:
None
Swelling (intra/extraoral)
Vague Pain
THERAPY:
Test
Result
(soft/hard/fluctuant)
Tooth
Caries control
Vital pulp therapy
Pain to heat/cold
Cellutitis
Cold
Apexification
Pain to sweet/sour
Sinus tract
Hot
Root canal therapy
Pain to mastication
Regional lymphadenopathy
EPT
Root canal retreatment
Spontaneous/on stimulus
Poor oral hygiene
Percussion
Surgical endodontics
Intermitten/continuous
Perio pocket (
Palpation
Extraction
Localized/diffused/radiating
Mobility (I/II/III)
Test Cavity
Others:
Severe/moderate/mild
Caries
Probing Depth
Duration: sec./mins./hrs.
Restoration (minimal/large)
mm)
Discoloration
MEDICAL ALERT:
Crown fracture (class:
Rheumatic fever
Tooth (canal) already opened
)
Rheumatic heart disease
High blood pressure
Drug allergy (
= Normal
AB = Abnormal
NR = No Response
Faculty Comments:
LR = Lingered Response
RADIOGRAPHIC EXAM:
)
Faculty Signature:
N
NLR = Nonlingered Response
Normal
Hepatitis/tuberculosis
Widen/thickened PDL
DIAGNOSIS:
Pregnancy
Apical/lateral rarefaction
a)
Others:
Internal/external resorption
Normal
Caries
Reversible pulpitis
REASON FOR TREATMENT:
Calcification/pulp stone
Irreversible pulpitis
Carious exposure
Root fracture (H/V)
Necrosis of pulp
Mechanical exposure
Furcation involvement
Elective endo treatment
Open apex
Trauma
Incomplete RCT
Normal
Perio
Broken instrument
Acute apical periodontitis
Cracked tooth
Perforation
Chronic apical periodontitis
Endo previously initiated
Others:
Acute apical abscess
Pulpal
Already Started
b)
Periapical
Overdenture
Chronic apical abscess
Others:
Condensing osteitis
Start Check:
Date:
Signature:
Name:
Number of canals
Total Points for
all canals
Points per canal
Extra Procedure
points
Total Points for
case
Computer No.: ________________________
GUIDELINES FOR EVALUATION
Session
Procedures
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No instructor's permission/sign
0 + suspension
-
No or improper Diagnosis
-2.5
History,
Examination,
Diagnosis
-
No or improper RD isolation
Failure/ -2.5
Patient
management/LA
-
Improper patient management
-2.5
Isolation
-
Ineffective LA
-2.5
Access cavity
ACCESS
1
2
3
Signature
4
5
6
N/A
Working length
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Under-extended
-1.5
Instumentation
-
Over-extended
-2.5
Obturation
-
Improper location/gouging
-3
Special Procedures
-
Perforation
0
Special Procedures
WL
Knowledge
-
Improper size
-3
-
Under/over ext. >2mm
-3
INSTRUM. MAC
Time Management
TOTAL GRADE [Faculty]:
-
Improper MAF
-3
-
Apical perforation
-3
-
Stripping perforation
0
-
Broken instrument
0
-
Flush
-3
-
Not flared
-3
Signature:
Course Director's Grade:
FINAL GRADE [out of 10]:
Root Canal
Signature:
Int WL
Ref. Point
S
WL
L
S
MAF
L
S
MC
L
S
OBTURATION
-
Short
-3
-
Over-extended GP
-3
-
Sealer ext.
-1
-
Voids apically
-3
-
Voids middle/coronal
-1.5
-
Flush
-2
-
No intermediate RG
-3
-
No final RG
-3
-
No final resto
-5
-
Treating wrong tooth
0 + suspension
Guarded
-
No medical history
0 + suspension
Surgery
Recall Examination
Prognosis
Findings
Date
Clinical
Good
Radiographic
Poor
Likely
Comments:
Faculty's Grade:
L
Sample Clinical Notes
20 year old female patient
 CC: “ I have a swelling and broken
down tooth in my mouth” points to URQ
 Med Hx: Juvenile Diabetes – controlled
with medication (Insulin Injections
2X/day)
 Dent Hx: Several extractions, fillings,
and RCT
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Pain: in URQ started 2 weeks ago,
wakes her up at night. Continuous,
throbbing, is not relieved by analgesics,
increases especially when drinking cold
and pain continues after removal of the
stimulus.
 EOE: NAD
 IOE: NAD tissues, large caries lesion in
#16
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Tests: #16:
– Pain on perc + palp
– Severe lingering pain with Ice test (Endo
frost)
– Early response with EPT
– No pockets
– No mobiliy
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Rad: small PA RL related to apex of #16
Diag: Irreversible pulpitis with chronic
PA periodontitis
 Tx plan: RCT, P+C, PFM Crown
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Tx today:
– IDNB 2% lidocaine – 2 carpules
– Isolation
– Caries excavation
– Access
– Filing and irrigation
MB
19.5 mm 30 k
DB
19.5 mm 30 k
P
21 mm
40 k
Dry canals
 Cotton pellet
 cavit
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Reference
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Principles & Practice of Endodontics 3rd
ed (2002) Walton & Torabinejad
Ch # 4
Homework
1.
2.
Write a table (or mind map) outlining
medical conditions that may
contraindicate or alter endodontic therapy
Outline clinical endodontic tests in a
thorough, logical manner (tables or
mindmaps can be used)
Next week’s lecture
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Isolation
Radiography
Access Preparation
& Length
determination
Cleaning & Shaping
Obturation
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Ch.8
Ch. 9
Ch. 12
Ch. 13
Ch. 14
Clinic
Attendance sheet will be removed after
15 mns
 You will have 2 patients each to
examine and fill out endo forms.
 Your instructor will show you how to
perform clinic tests for the whole group
 Don’t forget to sign evaluation forms
 Sign and dismiss patient @ 4:30 pm
PROMPTLY
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