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

2. Endodontic Diagnosis
To Treat or
not to Treat??

3. 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

4. Treatment Planning

5. 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

6. 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?

7. 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

8. 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?

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

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

11. 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

12. 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

13. 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

14. Cold Test Ice

15. Cold Test Tetrafluoroethane (Endo Ice)

16. 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

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

18. 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

19. Tests for Periapical Diagnosis
Percussion
Biting pressure
Palpation

20. 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

21. 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

22. Radiographic Exam
Radiolucencies
Caries
Restorability

23. Radiographic Exam Radiolucencies Caries Periodontal disease
Restorability
Periodontal disease

24. Radiographic Exam Parallel Shift

25. Radiographic Exam
Necessary for determining pulpal anatomy prior to access

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

27. Other Tests
Tooth Slooth

28. Other Tests
Transillumination

29. 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

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

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

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

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

34. 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

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

36. 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

37. 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

38. Post-Tx
13 Month Follow-up