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Diagnosis and treatment plan in Endodontic : Nawaf Hazaymeh

Majd Hidmi Sun. 21-4-2013

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Note before starting : The slides for this lecture include some pictures. Unfortunately , I couldnt add them due to protection on slides prevent copying anything !! -----------------------------------------------------------------------------------------------Lecture will be about the Diagnosis and treatment plan in Endodontic : Diagnosis is the science of recognizing disease by means of signs, symptoms, and tests. Often, diagnosis is straightforward; sometimes it is not. Now , we need to follow certain steps in oprder to reach a final diagnosis in odere to start our treatment . So the basic steps in the diagnostic process are : 1- Chief complaint : We need to listen to the patient ( to hear from the patient why hes coming to my surgery ? , why he is seeking my treatment ? ) , I need to hear from him his chief complain in his work , and I need to record I as it is . 2- History , ( medical and dental ) : In order to have a clear image of his dental & mediacal condition , in order to build up your treatment plan . If the patient said , he has gone through recent Myocardial Infarction & his tooth needs to be treated endodontically. so immediately it will come to your mind that this is a contraindication condition where you cant perform endodontic treatment , so this is a crucial point in your treatment. 3- Oral examination : Usually ,we start to make extraoral examination then we move to intraoral examination . So diagnosis is the key to the treatment . 4. Data analysis: in order to put your treatment plan . So, Diagnosis is the key to the treatment. differential diagnosis 5. Treatment plan

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The sequence of the events in the clinic when the patient arrive : 1- Medical History Review : you need to review his or her condition .( Update information about the patient : Allergies , Diabetes ,Pregnancy , Surgical issue ) 2- Subjective History 3- ObjectiveTesting 4- Analysis of data collected 5-Clinical diagnosis -------------------------------------------------1- Medical History Review Controlled Diabetes is not contraindication, but if its uncontrolled, we are afraid from infection also. Diabetic patient also is susceptible to infection more than the normal patient. You need to ask about the pain itself , about the duration itself , what factors may accelerate the pain , intensity of the pain. However , some patients are different of perception of pain . we need to ask the patient : does the pain come spontaneously , when you drink something , when you eat , when you open your mouth ?? Pulpal pain 1- Very poorly localized : sometimes the patient cant localize it whether its upper or lower jaw!! 2- Intermittent 3- Throbbing 4- Intensified by heat, cold and sometimes chewing 5- May be relieved by cold 6- Usually severe The pain is intensified by heat , and can be subside by cold .

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Periradicular pain 1234May be well localized Deep pain Intensified by chewing Moderate to severe in intensity

If the patient said the pain comes with heat or cold immediately , you think about puplalk pain . NOT LOCALIZED If the patient said when hes chewing it means something under the tooth ( periradicular ) , LOCALIZED

2- Subjective History
It will lead you to definitive diagnosis and determine the emergency of the case . It will be confirmed by the examination and performing the special tests.

Then you need to move to use your skills to confirm this diagnosis by examination by your naked eye , radiograph , percussion , Palpation ,Mobility,Thermal tests, Electric Pulp Test,Periodontal probing ,Selective anesthesia, Test cavity ,Transillumination ,Occlusion . You can use devices in your clinic also . What you look at your visual examination? 1- Extra-oral examination Facial asymmetry Swelling Extra oral sinus tract TMJ when you look at the patient , youll start to examine his face for asymmetric (swelling), you need to look if theres any sinus tract extra oral sinus and this is a long standing chronic inflammatory process in the periapical region . This kind of swelling after taking a radiograph it shows you radiolusency aroud molars .

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After that , you will move to intraoral examination : Soft tissue lesions - Swelling - Redness - Sinus tract : If the sinus is intraoral, this is also a chronic infection in one of the teeth , and In order to reach a final diagnoses we insert a Gutta Percha point inside this fistula,and it will lead to the tooth which cause this . Hard tissues - The teeth have caries - Large or defective restorations -Discolored/chipped teeth Radiograph *Always take your own pre-operative radiograph to know where youre standing. *Never make a diagnosis based on radiographic evidence alone Percussion test - it 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 Vertical : it will lead you to say this is a periapical lesion Horizontal : it will lead you to say this is a periodontal lesion

Palpation test Extraoral : To detect swollen or tender lymph nodes Intraoral : -May detect early periapical tenderness -Identifies soft tissue swelling -Must compare with other adjacent.
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-Mobility : we need to test these teeth for mobitiyin order to see if its a periodontally involved teeth or not , because once the tooth is periodontally involved and it stays for a long time . -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 ( Heat is the cause of the problem ) - Compare reaction with adjacent and contralateral teeth , - Refractory period of at least 10 minutes before pulp can be retested accurately - Isolate area with cotton rolls -Dry teeth to be tested , if its wet it may transfer this heat to the adjacent tooth *Ask patient to: Raise hand on feeling cold & Lower hand when cold feeling goes away It may give us Record: + or *sensitivity to cold *Time until cold sensitivity was felt *Time that cold sensitivity lingered Classic Responses to Thermal (cold) Testing: *Normal Pulp: Moderate transient pain *Reversible Pulpitis: Sharp pain; subsides quickly when you remove the cause *Irreversible pulpitis: Pain lingers , stay longer . *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 *we cant rely only on this test because: In multi-rooted teeth, where one canal is vital tooth usually tests vital
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*False positives and false negatives may occur! False positive reading: (from slides) *Electrode contact with metal restoration or gingiva *Patient anxiety *Liquefaction necrosis *Failure to isolate and dry teeth prior to testing False negative reading: (from slides ) *Patient is heavily premedicated *Inadequate contact between electrode and enamel *Recently traumatized tooth *Recently erupted tooth with open apex *Partial necrosis

Selective anesthesia may help us 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

Transillumination
It helps to identify vertical crown fracture Produces light and dark shadows at fracture site. ( when you suspect a fracture In that tooth and you cant see it , the fracture will reflect the light and it will appear as a dark line ). A crack will block and reflect the light when transilluminated

Analysis :
- Analyze the data gathered via: *History *Examination *Special tests - Arrive at a clinical (not histologic) diagnosis: *Pulpal diagnosis *Periapical diagnosis
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Possible pulpal Diagnosis *Normal *Reversible pulpitis *Irreversible pulpitis *Necrosis *Previous endodontic treatment Normal Pulp *Symptoms :None *Radiograph : No periapical change *Pulp tests : Responds normally *Periapical tests : Not tender to percussion or palpation Revesible Pulpitits *Symptoms : May have thermal sensitivity *Radiograph : No periapical change *Pulp tests : Responds sensitivity not lingering *Periapical tests Not tender to percussion or palpation

Irrevisible Pulpitis *Symptoms: May have spontaneous pain *Radiograph: No periapical change *Pulp Tests : Pain that lingers *Periapical tests: Generally not tender topercussion or palpation Nicrotic pulp *Symptoms : No thermal sensitivity *Radiograph : Dependent on periapical status *Pulp tests : No response *Periapical tests: Dependent on periapical status Possible periapical Diagnosis *Normal *Acute apical periodontitis *Chronic apical periodontitis *Chronic apical periodontitis with symptoms *Acute apical abscess *Chronic apical abscess *Condensing osteitis
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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 palpation High restorations, traumatic occlusion, orthodontic treatment, cracked teeth, vertical root fractures, periodontal disease and maxillary sinusitis may also produce the same symptomps , ( So Dont rely on single test ).

Chronic Apical Periodontits * Symptoms : None *Radiograph : Periapical radiolucency *Pulp tests : No response *Periapical tests: Not tender to percussion or palpation

Chronic Apical Periodontitis ( with Symptomps ) *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

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Chronic Apical Abscess *Symptoms : Draining sinususually no pain *Radiograph: Periapical radiolucency *Pulp tests: No response *Periapical tests: Not tender to percussion or palpation

Treatment & planning Treatment decisions are based on: *Pulpal diagnosis ( reversible , irreversible , chronic , acute ) *Periapical diagnosis *Restorability of tooth *Periodontal considerations *Difficulty of case *Financial considerations

Two major decisions: *Is root canal therapy indicated? *Should I carry out this treatment myself or should I refer it to specialist ?

There are some slides havent been mentioned from Dr. ( slides 64-75 )

And Thats it

Forgive me for any mistake Done by : Majd M. Hidmi

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