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 examination Facial 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

Characteristic J-shaped or halo lesion associated with 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

Used to assess cracked teeth and incomplete cuspal fractures Percussion Test Tooth Slooth Used to assess cracked teeth and incomplete cuspal fractures

Palpation Test Extraoral Intraoral 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 None Radiograph No periapical change Pulp tests Responds normally Periapical tests Not tender to percussion or palpation

Reversible Pulpitis Symptoms May have thermal sensitivity Radiograph No periapical change Pulp tests Responds – sensitivity not lingering Periapical tests Not tender to percussion or palpation

Irreversible Pulpitis Symptoms May have spontaneous pain Radiograph No periapical change Pulp Tests Pain that lingers Periapical tests Generally not tender to percussion or palpation

Necrotic Pulp Symptoms No thermal sensitivity Radiograph Dependent on periapical status Pulp tests No response Periapical tests 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 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 this response

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

Chronic Apical Periodontitis with symptoms 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

Chronic apical abscess Symptoms Draining sinus – usually no pain Radiograph Periapical radiolucency Pulp tests No response Periapical tests Not tender to percussion or palpation

Condensing Osteitis Symptoms Variable Radiograph Increased bone density Pulp tests Dependent on pulp status Periapical tests +/- 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 Intra-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 14 15 3 Percussion Negative Thermal Normal No response EPT 56 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