Endodontic

Diagnosis And
Treatment
Plan

Dr. Hadil Abdallah Altilbani

BDS Santiago de Compostela University Spain.
MSc. University of Valencia Spain.
Department of Endodontics University of Palestine .
ART AND SCIENCE
OF DIAGNOSIS
The journey to definitive treatment begin with accurate diagnosis.
However, accurate diagnosis is not always possible, due to complexity of the
symptoms and many diseases share the same signs and symptoms.
Also it established that histological condition of the pulp does not relate to the
sign and symptoms.

The basic steps in diagnostic procedure are:

 Chief complaint
 History (medical and dental)
 Oral examination
 Clinical tests
 Data analysis and differential diagnosis
 Treatment plan
 Tools Of Diagnosis

Knowledge
Compassion
Patience
Curiosity
Management
Listening : Art Of Listening Is
Most Important As It Establishes
A Rapport ,Undersatndind And
TRUST
There are limited numbers of possible diagnosis for pulpal and
periapical conditions, that includes:

Pulpal diagnosis:
Normal
Reversible pulpitis
Irreversible pulpitis (symptomatic/ asymptomatic)
necrosis

Periapical diagnosis:
Normal
Symptomatic apical periodontitis
Asymptomatic apical periodontitis
Acute apical abscess
Chronic apical
 ANAMNESIS

 Chief Complaint
SUBJECTIVE  Medical History
INFORMATION
 Dental History
 History of Present Dental Problem

 Dental History Interview

 CHIEF COMPLAINT
 This is the first information that
volunteered by the patient and should
be recorded in the exact formula.

 It can help in both diagnosis and

treatment plan because these comments
are direct and non-biased.

• In patient’s own words

– “My tooth hurts when I chew hard foods”
– “I can’t drink cold soda”
Medical history
Apart from its medico-legal importance, it is important because it
may influence the therapy to some degree.
 Medical history
 The clinician should be aware if the patient has drug allergies or allergies
to dental products
Medical conditions that may have oral manifestations or mimic dental
pathosis
 Medical Conditions that may require a modification in treatment plan
 If the patient had a prosthetic heart valve replacement
 a history of rheumatic fever or a malignancy requiring chemotherapy or
radiotherapy, the endodontic treatment will have to be performed with
antibiotic prophylaxis.
 Patients with hepatitis, herpes, or AIDS, it is not only the patient who
must be protected from infections, but also the dentist and the staff.
 If the patient is under treatment for other reasons and there is concern
regarding drug interactions, it is always prudent to consult with the
patient’s physician.
 DENTAL HISTORY

Investigate past dental history for recent trauma,

recent restoration or periodontal treatment, and
previous treatment for TMJ dysfunction.
 DENTAL HISTORY INTERVIEW

The dentist should interview (ask) the patient about the symptoms
he has to get the full idea of ‘what’ is happening and ‘why’ it is
happening.

 Patient may complain from:

 Pain
 swelling
 Sinus tract
 Broken tooth
 Loose tooth
 Tooth discoloration
 Bad taste
Pain
Is the clinical symptom associated with most
inflammatory pulp diseases.

Pain, is the only feature of inflammation

that accompanies pulpal inflammation
Marking the intensity of pain

Patient is asked to mark the imaginary ruler with grading ranging from 0 to 10
0-No pain 10-Most painful
If patient complain of PAIN
ask him the following questions:

 When did pain begin?

 Where is the pain located?
 What is the character of the pain (short, sharp, long, lasting, dull, throbbing,
continuous, occasional)?
 Is the pain always in the same place?
 Is the pain worse in the morning?
 Is the pain worse when you lie down?
 Is the pain continuous, spontaneous or intermittent?
 Doses the pain prevent sleeping or working?
 Did or does anything initiate the pain (trauma, biting, thermal)?
 Once initiated, how long Does the pain last?
 Does anything make the pain worse (hot, cold, biting)? Does anything make
the pain better (cold, analgesics)?
 Similarly, if patient is
presented with swelling,
take history of:

When did the swelling begin?

How quickly has the swelling increased in size?
Where is the swelling located?
What is the nature of the swelling (soft, hard, tender)?
Is there drainage from the swelling?
Is the swelling associated with loose or tender tooth?
 WHAT INDICATE A DIFFICULT DIAGNOSIS?
The following presentations may indicate a case that is difficult
diagnositically:

Patient can not localize the pain source

No local dental cause for the pain can be identified (no caries,
no restoration, etc..)
Pain is spontaneous or intermittent
Stimulation of suspected tooth (using vitality tests) does not
produce symptoms
More than one tooth is suspected
Symptoms are bilateral
Selective anesthesia fail to localize the source of pain
 EXTRAORAL EXAMINATION
Clinician should look and analyze the patient as soon as he enter the
room.
Look for general appearance, skin tone, facial asymmetry, swelling,
discoloration, redness, extraoral scars, sinus tracts and
lymphadenopathy.
Palpation of face and neck area is also important, to check for swelling or
tenderness.
Many times these swelling are not clear visually, and require palpation to
identify.
Palpation of cervical and submandibular lymph nodes is important part of
diagnostic procedure. If there is swelling or feels firm and tender, with
elevated temperature, then these is greater chance of systemic
involvement.
Loss of definition of nasolabial fold on one side of the nose may be the
earliest sign of canine space infection. This can result from infected maxillary
canine, or long-rooted incisors.
 EXTRAORAL EXAMINATION
 Face (gross abnormality)
 Skin(pallor , pigmentation and cyanosis)
 Hair(alopecia ,hirrusitism )
 Nails(clubbing)
 Eyes( anaemia and jaundice)
 Nose(nasal deviations)
 T M J (deviation of mandible , any mass over TMJ ,
tenderness on palpation, clicking sounds)
 Lymph nodes of head and neck (site , size, number,
consistency , tenderness ,fixity )
 Salivary gland( enlargement of major glands, dryness of
mouth, quantity and character of secretion)
Facial Asymmetry
Loss of definition of the nasolabial fold
may be the earliest sign of a canine space infection (Spilka 1966)
Extraoral Sinus Tracts
Palpating submandibular salivary gland
Palpation
Bimanual examination is also performed to investigate the condition of the
submandibular or cervical lymph nodes .
TMJ
1. • Standard of oral hygiene.
2. • Amount and quality of restorative work.
3. • Prevalence of caries.
4. • Missing and unopposed teeth.
5. • General periodontal condition.
6. • Presence of soft or hard swellings.
7. • Presence of any sinus tracts.
8. • Discoloured teeth.
9. • Tooth wear and facets.
INTRAORAL EXAMINATION
Oral tissue is dried and examination begin of the lips, oral
mucosa, cheeks, tongue, periodontium, gingiva, palate and
muscles.
Look for any sign of discoloration, inflammation, ulceration,
and sinus tract formation.

Sinus tract can be traced to its source using gutta-percha points size #25 or #30
and inserted into the opening until resistance is felt. It may cause slight
discomfort to the patient.
Examine teeth with mirror and explorer and look for
discoloration, fracture, abrasion, attrition, erosion, caries,
defective restoration, or other abnormalities.

A discolored crown can be an indication of pulp pathosis.

Ulceration
In examining the soft tissues, one must search for leukoplakia, precancerous or
cancerous lesions of the oral cavity, fistulae, swelling or erythema, scars, and
evidence of prior periapical surgery .
Swelling in the anterior part of the palate is most frequently associated with an
infection present at the apex of the maxillary lateral incisor or the palatal root of
the maxillary first premolar
Examination of soft tissues, alveolar mucosa and attached gingiva is done
for any inflammation , ulcerations or sinus tracts.
A sinus tract traced with a gutta-percha cone
The teeth are examined for any caries, defective restorations, erosions, abrasions,
cracks, fractures, and discolorations like ‘pink spot which is indicative of internal
resorption.
 PERIODONTAL EXAMINATION
Mobility
 Examine mobility of the tooth by placing the back end of mirrors on both buccal and
lingual surface of the tooth, then apply pressure in bucco-lingual direction and also in
vertical direction.
 Any movement more than 1 mm should be considered abnormal.
 Increased mobility does not mean the pulp is not vital, mobility is an indicative of the
status of the periodontal attachment.
 Increased mobility can occur due to trauma, occlusal prematurities, rapid orthodontic
movement, parafunctional habits, periodontal diseases, root fracture or pulpal diseases.

Probing
 Probing is an important step in diagnosis. Teeth with wide periodontal pocket usually are
periodontal in origin, while teeth with narrow localized pocket are usually endodontic in
origin, or could be vertical root fracture.
 Furcation bone loss could be periodontal or endodontic in origin, and should be recorded
in the chart.
 may be of
an endodontic etiology, specifically from a
nonvital tooth whose infection has extended
from the periapex to the gingival sulcus.
can be secondary to
periodontal or pulpal disease.
The lateral incisor tested vital and the abscess was a periodontal abscess
that was initiated with pockets starting in a cingulum groove of the
palatal surface.
 CLINICAL TESTS
These include:
Palpation
percussion
Thermal tests
Electric pulp test
Bite test
Test cavity
Staining and transillumination
Selective anesthesia

These has been discussed extensively in previous lectures, however, a short

overview will be presented here.
 PALPATION
Firm digital pressure with Index Finger is applied to the apical
area of the tooth, and adjacent teeth.

Any soft tissue swelling, bony expansion should be noted and

recorded.

Pain or tenderness during the procedure should be recorded

too.
This may indicate an active periapical inflammation, however, it
does not determine whether it is endodontic or periodontal in
origin.
Palpation

This will detect the

presence of
periradicular
abnormalities or ‘‘hot’’
zones that produce
painful response to
digital pressure.
In the case of an abscess,
it may furthermore be
useful to perform a
bimanual
examination using the
two index fingers, to
assess whether the
underlying swelling is soft
and fluctuant .
 PERCUSSION
This test is performed when the patient complain of pain during
biting or mastication.

Pressure is applied with index finger on the incisal/occlusal

surface of the tooth vertically and horizontally.

The adjacent teeth should be tested first to serve as control and

to know the normal response of the patient.
If patient does not report any pain after completing this test,
then a blunt instrument is used to tap on the tooth.
This Test Does Not Indicate The Status Of The Pulp, Rather It
Indicate Presence Of Inflammation In The PDL.
Percussion is first performed gently with the right index finger (always beginning
with the least suspect tooth so as not to frighten the patient), and then percuss the
occlusal, buccal, and lingual surfaces with the handle of the dental mirror .
 The percussion test determines the presence of inflammation in the periodontal ligament,
but gives no information about the state of health of the pulp.
 Percussion stimulates the proprioceptors of the periodontal ligament.
The test can be used to diagnose an acute apical periodontitis, the consequence of pulp
inflammation or result of occlusal trauma or periodontal disease.
 THERMAL TESTS
These include cold test, and heat test.

Cold test can be used with ice sticks, dry ice (co2), or refrigerant spray.
Adjacent teeth should be isolated with gauze to prevent false-positive results,
then cold instrument is applied to the tooth surface and response is waited.
If patient response to the test and pain subside after removal of the instrument then
the pulp is normal.
If pain does not diminish or rather increase after removal of the instrument then this
tooth most likely has a pulpal pathosis.

Heat test can be applied using heated water with syringe (after isolation with
rubber dam), heated gutta-percha (remember to add lubricant to the tooth surface to
prevent adhesion of gutta-percha to the tooth), or the use of rotating rubber cup (not
recommended).
Cold test has been reported to be equal or even superior to electrical pulp testing
according to several studies.
 Ice Sticks
They can be produced by filling
with water the disposable
anesthetic needle holders and
placing them in the freezer
compartment of the
refrigerator.
When needed, the top of the
plastic container is removed,
leaving a stick of ice about 3 cm.
long, which will more than
suffice for testing the teeth of
an entire quadrant
This can be performed by spraying

Ethyl Chloride on the cervical area

of a tooth or on a cotton pellet held in
pliers and then placing it at the cervical
area of the dried tooth.
The second method is preferable, as ethyl
chloride is a highly flammable anesthetic
and potentially dangerous.
The sprayed cotton pellet
should be applied to the
midfacial area of the tooth or
crown.
The response of a normal pulp to cold stimulus is
identical to that to a hot stimulus:

The pulp has no specific receptors, and the neural fibers in the
pulp transmit only the sensation of pain.
The patient should not feel pain, but only a moderate sensation,
which recedes immediately after the removal of the stimulus.

The lack of response may suggest either a necrotic

pulp or a false-negative response due for example to excessive
calcification, an immature apex, recent trauma, or patient
premedication.
To perform the heat test on teeth with full gold crowns, one can use a polishing rubber disk in
a rotary handpiece revolving at a low speed, generating frictional heat against the metal.
If the tooth is covered by a ceramic-metal crown, the test is performed at the lingual cervical
area, where there is usually some exposed metal surface.
ELECTRICAL PULP
TEST
This test does not indicate the
presence of vascular supply in
the pulp (a sign of vitality), but
rather indicate the presence of
intact nerve fibers.
It has been reported that
electrical pulp testing is most
accurate when detecting necrotic
teeth.
 BITE TEST
It begin by applying firm
pressure using cotton tip
applicator, toothpick, or tooth
slooth on each cusp of the
tooth.
Patient will report pain when
there is apical pathology or
root fracture.
Sometimes patient feel pain
when the instrument is
removed, which may indicate
a fractured tooth or root.
A common finding with a fractured cusp or cracked tooth is the frequent presence
of pain upon release of biting pressure.
* The tooth may be sensitive to biting with periradicular periodontitis and
a cracked tooth or fractured cusp. (Cameron 1981)
 TEST CAVITY
This test is not recommended
because it is an invasive procedure.
It only used when other test results
failed to determine the condition of
the pulp.
A bur in high speed with water
coolant is used to drill the tooth,
when dentin is reached the patient
will feel pain which indicate vital
pulp tissue. However, when no pain
is felt then the tooth is necrotic and
the procedure is continued to
access opening and further
endodontic treatment.
STAINING AND
TRANSILLUMINA
TION

Stains can be used to

determine the presence of
fracture in the root.
Also tranillumination with
strong fiberoptic light can
determine the fracture site.
Area that is close to the light
source will appear bright,
while area beyond the
fracture will appear dim.
Fibre-optic light
transilluminating
 SELECTIVE ANESTHESIA
It used when other tests are inconclusive.
PDL injection is applied to each tooth,
starting from the maxilla.
A most posterior tooth should be
anesthetized first and progressing
anteriorly.
If all teeth in maxilla anesthetized and pain
is still present, the same procedure is
applied to the mandible until pain
disappear.
However, it should noted that PDL
injection can anesthetize more than one
tooth at a time which make it less useful in
determining which tooth is the source of
pain.
Therefore, this technique is most useful in
recognizing which arch (maxilla or
madibule) is the source, and not a specific
tooth.
 RADIOGRAPHIC
EXAMINATION
The value of radiographic image
are sometimes overestimated by
the clinician.
Proper diagnosis and clinical
tests are necessary, and
radiograph is only
supplementary.
Traditional radiography is two-
dimensional presentation of
three-dimensional structures,
therefore multiple radiograph
should be taken from different
angles to visualize more hidden
structures.
A well-prepared
radiograph can find
multiple canals, multiple
roots, resorption, caries,
defective restoration,
root fracture and state of
root maturation and
apical development.
Periapical pathology can be presented
radiographically with:
The lamina dura is absent apically
Radiolucency at the apex

However, not all apical pathosis are seen on

radiograph, especially early lesions.
Studies has found that radiolucency on
radiograph can be seen only when pathosis
reach the cortical bone, it can not be seen
when presented in cancellous bone.
The root apecies of most anterior and
premolars are close to the cortical bone,
therefore seen early. While molar teeth are
found in the cancellous bone, therefore not
seen early in the radiograph.
Absence of radiolucency in the the
radiograph does not mean there is no
pathology, other clinical tests should be
performed to reach that level of diagnosis.
 Lamina dura is the most consistent radiographic
finding when tooth is not vital.
 If lamina dura is widened, or intermitted then it
can be an indication of pulpal pathosis.
 In addition to that, radiograph can shows
presence of pulp calcifiction, or canal
obliteration due to dentin formation, and these
conditions are normal and need no intervention
unless pulp is offended.
 It worth mentioning that more advance
radiographic has been incorporated in dental
practice in recent years with superior imagining
qualities compared to conventional 2D
radiograph.