Endodontic Diagnosis & Treatment Planning Dental History Endodontic Diagnosis & Treatment Planning Medical History Chief Complaint B. Retamozo DDS, MSD Department of Endodontics

Endodontic Diagnosis To Treat or not to Treat??

Clinical Diagnosis 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

Treatment Planning

Components of Diagnosis Assemble facts Chief complaint Medical history Dental history History of the present condition Objective exam Interpret the clues Differential diagnosis Final diagnosis

Chief Complaint 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?

Medical History 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

History of Present Condition How long? How much has it been bothering patient? Any medications? Does any specific activity precipitate painful episode? Chewing Prevent sleep?

Dental History Recent dental work Recent trauma Cleaning Fillings Crowns Root Canal Therapy Recent trauma

Objective Examination Soft tissue Pain to palpation Swelling Sinus tract Lymph node enlargement Dentition Caries Discolorations Fractures Abrasions

Endodontic Diagnosis Initial Tissue damage Long term tissue damage Acute Chronic Initial Tissue damage Long term tissue damage Fast Process Slow process Painful Response Lower Response

Control Teeth for Pulp Testing Use adjacent teeth Localize within an arch Use contra-lateral teeth You are assessing the patient’s response to a stimulus

Tests for Pulpal Diagnosis 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

Cold Test Ice

Cold Test Tetrafluoroethane (Endo Ice)

Tests for Pulpal Diagnosis 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

Tests for Pulpal Diagnosis Necrotic pulp indicators Swelling Drainage Tracking with gutta percha

Pulpal Diagnosis Thermal Test No Response Normal Pulp Sharp pain goes away quickly No Response Hypersensitive pain goes away quickly Severs sensitivity that lingers Normal Pulp Reversible Pulpitis Irreversible Pulpitis Necrotic Pulp

Tests for Periapical Diagnosis Percussion Biting pressure Palpation

Percussion Response indicates the involvement of the PDL Degree of response is directly proportional to the degree of inflammation Chronic periapical inflammation is often negative

Periapical Diagnosis Percussion Swelling No Pain Pain Swelling Drainage Sinus Tract Swelling No Yes No Yes Symptomatic Apical Periodontitis Acute Apical Abscess Asymptomatic Apical Periodontitis Chronic Apical Abscess

Radiographic Exam Radiolucencies Caries Restorability

Radiographic Exam Radiolucencies Caries Periodontal disease Restorability Periodontal disease

Radiographic Exam Parallel Shift

Radiographic Exam Necessary for determining pulpal anatomy prior to access

Other Tests Mobility PPD’s Indicates the integrity of the attachment apparatus PPD’s

Other Tests Tooth Slooth

Other Tests Transillumination

Interpretation 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

Assessment of Pulpal Conditions Normal Reversible Pulpitis Irreversible Pulpitis Necrotic Previously initiated Previously treated

Clinical Signs and Symptoms Normal Pulp Responds to cold, but no pain Responds to EPT

Clinical Signs and Symptoms Reversible Pulpitis Exaggerated response to cold, but pain does not linger Responds to EPT Sensitive to Sweets

Clinical Signs and Symptoms Irreversible Pulpitis Pain to cold that lingers May or may not have pain to heat Spontaneous intermittent pain Constant pain

Clinical Signs and Symptoms 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

Diagnosis of Periradicular Tissues Normal Symptomatic Apical Periodontitis Asymptomatic Apical Periodontitis Acute Apical Abscess Chronic Apical Abscess

Case #1: Barbara complains of pain to cold on lower right Pulpal Dx: Irreversible Pulpitis Apical Dx: Symptomatic apical Periodontitis Plan: RCT Tooth # Cold Hot Percussion EPT PPD’s 29 + - 23 WNL 30 +++ 21 31 32

Case #2: Arturo complains of pain and swelling on lower left Pulpal Dx: Necrotic Apical Dx: Symptomatic apical Abscess Plan: RCT Tooth # Cold Hot Percussion EPT PPD’s 18 - +++ N/A WNL 19 20 + Large buccal swelling present#18

Post-Tx 13 Month Follow-up