Endodontic Assessments in a Differential Diagnosis The Endodontic- Restorative Continuum Alan H. Gluskin DDS Professor and Chair Department of Endodontics

The Role of Endodontic Vitality Testing in a Differential Diagnosis

Endodontic Differential Diagnosis Medical / Dental Extraoral Examination Intraoral Examination Tactile Exam Definitive Diagnosis Vitality Tests Radiographs

Extraoral Visual Examinations Facial Asymmetry ? Yes / No Aggressive Swelling ? Yes / No Facial Injuries ? Yes / No Purulent Drainage ? Yes / No

Intraoral Visual Examination Palpation Radiographs ProbingsPercussionMobility

Palpation / Digital Examination Palpation Examination Light Digital Pressure Soft Tissues Location Indurated, Swollen Fluctuant Pain Intensity No Pain, Tender, Acute Pain

Intraoral Visual Examination

Oops

Endodontic Assessments in a Differential Diagnosis The Endodontic- Restorative Continuum Alan H. Gluskin DDS Professor and Chair Department of Endodontics

Vitality Assessment & Tools Thermal Cold Heat Vital Test Cavity Electric Pulp Tester Selective Anesthesia Tooth Slooth™ Fiber Optic Light Tentative Diagnosis

Establish A Point of Reference Challenge Adjacent/ Contralateral Tooth Challenge Opposing Tooth or Arch Challenge Tooth in Question Challenge Quadrant

Vitality Assessment & Tools Thermal Cold Heat Vital Test Cavity Electric Pulp Tester Selective Anesthesia Tooth Slooth™ Fiber Optic Light Radiographs

Tooth Responses Hypo Responsive W.N.L. Hyper Responsive Responses From Tooth (-) (-) / (+) (+ +), (+ + +) MomentaryLingersSpontaneous

Endodontic Differential Diagnosis Medical / Dental Extraoral Examination Intraoral Examination Tactile Exam Definitive Diagnosis Vitality Tests Radiographs

Dental History - The Science Recognize Understanding Interpreting

Dental History - The Art Asking the RIGHT questions ACTIVE listening

Dental Emergencies Tooth Trauma Toothache Toothache Non-Pulpal Involvement Tooth Knocked Out Loose Tooth Fractured Tooth Chipped Tooth Concussion

Diagnosing Oro-facial Pain Dental Non-Dental

Interpreting the Language of Pain Subjective Coloring Acute Acute Chronic Low Grade Pain Hx of Pain IntenseSharp Spon- taneous Deep, Gnawing

Understanding the Language of PainSignsSymptoms DentalNon-DentalDentalNon-Dental +

Inflammation Cellular Neurologic Vascular Humoral

Language of Pulp Pain Dental Pulp Pulpal Inflammation AsymptomaticSymptomatic AcuteChronic

Physiology of Pulpal Pain A-Delta Fibers Pain Human Dental Pulp Afferent Impulses C-Fibers

Physiology of Pulpal Pain A-delta Fibers: –Located in Pulp-Dentin Interface –Myelinated –Large Diameter

A-delta Fibers – Cold / Heat Thermoreceptor for Pain Quick Sharp Short

Physiology of Pulpal Pain C- Fibers: ·Located Centrally in the Pulp ·Unmyelinated ·Small Diameter

C-Fibers - Heat Thermoreceptor for Pain Steady Dull / Gnawing Prolonged / Spontaneous

Acute Pulpal Origin Acute Pulpal Pain Temporary Pain Short Duration Cold AbscessSpontaneous Constant Pres- sure Swell- ing Fever Heat Increa -sing Cold Hot Throb -bing Cold Relief DiffuseLocalized

Chronic Pulpal Origin Chronic Pulpal Pain DullIntermittentRecurrent Deep Acute Tolerable Acute Acute Acute

Endodontic Assessments in a Differential Diagnosis The Endodontic- Restorative Continuum Alan H. Gluskin DDS Professor and Chair Department of Endodontics

Mobility - Depressibility Examination Integrity of the Attachment Apparatus

Tooth Mobility Evaluation Mobility Examination Light Lateral Pressures Adjacent Teeth Suspect Teeth Class I Class II Class III

Periodontal Ligament Reaction

Trauma Vital Pulp Necrotic Pulp P.D.L. Reaction HealthySick Egressing Out Perio Disease Egressing Out

Thermal Responses

Cold Stimulus Challenge ColdTest Tooth Ethyl Chloride RefrigerantsIce Hyper Response CarbonIce W.N.L. Hypo Response Relief

Cold Test

Heat Challenge

Heat Stimulus Challenge HeatTest Tooth Warm Gutta Percha Hot Tap Water Hyper Response Rubber Disc Friction W.N.L. No Response Delayed Response

Early Pulpal Injury Thermal Challenge Normal Pulp Inflamed Pulp Aged Pulp Late

Neural Responses

Electric Response Assessment Electric Pulp Tester Adjacent Tooth Suspect Tooth Contralateral Tooth Hyper Response W.N.L. Hypo Response No Response

Neuron Activity Neural Responses Vital Pulp Necrotic Pulp Total Necrosis Partial Necrosis Aged Tissues Trauma to Pulp Young Tissues

Sensory Pathways

Identifies Source of Tooth Pain Sensory Pathways Identifies Referred Pain From Tooth Identifies Non - Tooth Pain

Anesthetic Diagnosis Selective Anesthesia Ligamental Injections Local Anesthesia Relieves Suspect Tooth RegionalBlocks Reveals Referral Pain Reveals Trigger Sites Reveals Referral Pain

Test Cavity Challenge

Test Cavity No Anesthetic Prepare Shallow Access Penetrate Into Dentin / Chamber No Response Slight Response Acute Response Pulpal Necrosis Degenerating Pulp Vital Pulp

100% Healthy Extent of Pulp Vitality Test Cavity Vital Pulp Endodontic Access Necrotic Degenerating

Fractured Tooth Assessment Tooth Slooth™ Bite & Release Sharp Pain Engage Cusp Tip Shallow Fx Cuspal Fx Vertical Fx Horizontal Fx No Pain

Occlusal Provocation

VitalTooth Damage to Crown NecroticTooth Damage to Root Damage to Socket

Crack Detection

Tooth Slooth™

Checking for crack/fracture

Crack MB cusp

Deep isolated pocket

Transillumination

Fiber Optic Light Exam Thru Cervical Line Light Conductance Through & Through Abrupt Stoppage Surface Crazing Thru Line Angles Thru Cusps Tips

Superficial Cracks Transillumination Hard Tissue Integrity Deep Fractures Moderate Crazing

Acute Crack

Misdiagnosis

The Endodontic- Restorative Continuum

Decision Making

Host Resistance Endo - Perio Patient Dental I.Q. Operator Limitations How Critical is Tooth? Cost Effectiveness Treatment Alternatives Sequence of Treatment Use of Specialist History Etiology Endo and / or Perio

Determination of Prognosis Periodontal Prognosis Endodontic Prognosis Restorative Prognosis

Periodontal Prognosis Bone loss Pocketing Health of Periodontium

Periodontal Concerns General periodontal status Isolated periodontal defect

Endodontic Prognosis Vitality Periapical area Canals negotiable? Posts present?

Endodontic Diagnosis Vital Tooth Reversible Irreversible

Electric Pulp Tester

Cold Test

Tooth Restorability Caries Chip in enamel Chip into dentin Cusp fracture Tooth fracture Root amputation

Restorative Prognosis determined by… Structural Integrity

Treatment Alternatives Restore as is... Restore as is... and extract Extract –No further treatment –Fixed partial denture –Removable partial denture –Implant and hope

Financial Considerations At UOP In Private Practice

Ferrule Effect What is it? Facial/Lingual vs Mesial/Distal Anterior Tooth Posterior Tooth How wide / thick?

How to achieve the ferrule Prep into sulcus Crown lengthening Extrusion

Ferrule mm long mm long Parallel wallsParallel walls Totally encircle toothTotally encircle tooth End on sound tooth surfaceEnd on sound tooth surface Not invade attachment apparatusNot invade attachment apparatus

Core Replaces missing tooth structureReplaces missing tooth structure Supports rehabilitationSupports rehabilitation

Core Materials Cast metalCast metal AmalgamAmalgam Composite resinComposite resin Glass Ionomer / Glass Ionomer Silver materialsGlass Ionomer / Glass Ionomer Silver materials

Fractured Cusp into Furcation

Crown/restorative disassembly

Tooth isolated for endodontics

Resin syringe

Build-up matrixed

Crown lengthening

Post-op crown lengthening