1. Diagnosis and Treatment Planning

2. Definition
Diagnosis is the determination of the nature of a diseased condition by careful investigation of its symptoms and history

3. Sequence of Events Medical History Review Subjective History
Objective Testing
Analysis of data collected – Clinical diagnosis
Plan of Action

4. Medical History Review
Review/update written medical questionnaire
Medications
Allergies
Need for SBE prophylaxis
Diabetes
Pregnancy
Written consultation with physician as required

5. Medical History Review
SBE Prophylaxis
Required for endodontic treatment in at risk patients
AHA recommendations should be followed

6. Medical History Review
Prescribe:
2 grams Amoxicillin 1 hour prior to treatment
Clindamycin 600 mg for penicillin allergic patients

7. 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

8. Medical History Review
Pregnancy
Avoid treatment in first and third trimesters
Keep radiographic exposure to a minimum

9. 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

10. Medical History Review
The only systemic contraindications to endodontic therapy are:
Uncontrolled diabetes
A very recent myocardial infarct

11. Subjective History Chief complaint In patient’s own words
“My tooth hurts when I chew hard foods”
“I can’t drink cold soda”

12. Pain History

13. Subjective History Pain History Location Intensity Duration Stimulus
Relief
Spontaneity

14. Pulpal Pain Very poorly localized Intermittent Throbbing
Intensified by heat, cold and sometimes chewing
May be relieved by cold
Usually severe

15. Pulpal Pain

16. Periradicular Pain May be well localized Deep pain
Intensified by chewing
Moderate to severe in intensity

17. Periodontal Pain May be well localized Intensified by chewing
Moderate to severe in intensity

18. Periradicular /Periodontal Pain

19. Subjective History Gives rise to tentative diagnosis
Determines urgency of treatment
Confirmed by examination and special tests

20. Objective Testing Visual Examination Radiographs Percussion Palpation
Mobility
Thermal tests

21. Objective Testing Electric Pulp Test Periodontal probing
Selective anesthesia
Test cavity
Transillumination
Occlusion

22. Visual Examination Extra-oral examination Facial asymmetry Swelling
Extra oral sinus tract
TMJ

23. Extra-oral Swelling

24. Visual Examination
Extra oral sinus tracts associated with necrotic teeth

25. Visual Examination Intra-oral examination Soft tissue lesions Swelling
Redness
Sinus tract

26. Acute apical abscess
Acute apical abscess
Incision and drainage

27. Visual Examination
A sinus tract should be traced with a gutta-percha cone

28. Visual Examination Hard tissues Caries Large or defective restorations
Discolored/chipped teeth

29. Discoloration

30. Radiographs Always take your own pre-operative radiograph
Never make a diagnosis based on radiographic evidence alone

31. Radiographs Consider taking a bitewing film of posterior teeth
Note characteristic appearance of fractured root

32. Characteristic J-shaped or halo lesion associated with fractured root
Radiographs
Characteristic J-shaped or halo lesion associated with fractured root

33. 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

34. Percussion Test
Vertical percussion
Horizontal percussion

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

36. 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

37. Palpation

38. 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

39. 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

40. Thermal Tests

41. Thermal Tests
CO2 Snow
Ice stick

42. 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

43. 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)

44. 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

45. 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

46. Electric Pulp Test

47. 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

48. Electric Pulp Testing

49. 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

50. Periodontal Examination

51. Periodontal Examination
An isolated deep pocket may indicate a root fracture

52. 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

53. Test Cavity Initiation of cavity preparation without anesthesia
Test of last resort

54. Transillumination Helps to identify vertical crown fracture
Produces light and dark shadows at fracture site

55. Transillumination
A crack will block and reflect the light when transilluminated

56. Occlusion
Hyperocclusion – a possible cause of percussion sensitivity

57. Analysis Analyze the data gathered via: History Examination
Special tests
Arrive at a clinical (not histologic) diagnosis:
Pulpal diagnosis
Periapical diagnosis

58. Possible Pulpal Diagnoses
Normal
Reversible pulpitis
Irreversible pulpitis
Necrosis
Previous endodontic treatment

59. Normal Pulp Symptoms None Radiograph No periapical change
Pulp tests Responds normally
Periapical tests Not tender to percussion or
palpation

60. 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

61. 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

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

63. Possible Periapical Diagnoses
Normal
Acute apical periodontitis
Chronic apical periodontitis
Chronic apical periodontitis with symptoms
Acute apical abscess
Chronic apical abscess
Condensing osteitis

64. Normal Periapex Symptoms None Radiograph No periapical change
Pulp tests Responds normally
Periapical tests Not tender to percussion or palpation

65. 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

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

67. Chronic Apical Periodontitis with symptoms
Symptoms Pain on pressure
Radiograph Periapical radiolucency
Pulp tests No response
Periapical tests Tender to percussion and/or palpation

68. Acute Apical Abscess Symptoms Swelling and severe pain
Radiograph +/- periapical radiolucency
Pulp tests No response
Periapical tests Tender to percussion and palpation

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

70. Condensing Osteitis Symptoms Variable
Radiograph Increased bone density
Pulp tests Dependent on pulp status
Periapical tests +/- tenderness to percussion and palpation

71. Treatment Planning Treatment decisions are based on: Pulpal diagnosis
Periapical diagnosis
Restorability of tooth
Periodontal considerations
Difficulty of case
Financial considerations

72. Treatment Planning Two major decisions:
Is root canal therapy indicated?
Should I carry out this treatment myself or should I refer the case?

73. Factors that add risk to Endodontic Cases
Patient considerations
Objective clinical findings
Additional conditions

74. Patient Considerations
Medical history
Local anesthetic considerations
Personal factors and general considerations

75. Objective Clinical Findings
Diagnosis
Radiographic findings
Pulpal space
Root morphology
Apical morphology
Malpositioned teeth

76. Additional Conditions
Restorability
Existing restoration
Fractured tooth
Resorptions
Endo-perio lesions
Trauma
Previous endodontic treatment
Perforations

77. 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

78. AAE Case Difficulty Assessment Form

79. 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

80. Presenting complaint
“ I had a crown placed about 6 years ago and now but I have a blister over that tooth”

81. 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

82. Medical History
Allergy to penicillin
Aspirin upsets pt’s stomach

83. Subjective history No subjective symptoms
Pt reports presence of ‘blister’ on gum

84. 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

85. 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

86. Special tests Tooth # 13 14 15 3 Percussion Negative Thermal Normal
No response
EPT 56
Not possible to test 49

87. Pre-operative film

88. Diagnosis Pulpal necrosis Chronic apical abscess RCT and restoration
Medical history does not affect treatment plan

89. Access and Working length

90. Completed RCT

91. Summary Pulpal Diagnoses Normal Reversible pulpitis
Irreversible pulpitis
Necrosis

92. Summary Periapical Diagnoses Normal Acute periradicular periodontitis
Chronic periradicular periodontitis
Acute apical abscess
Chronic apical abscess
Condensing osteitis

93. 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

94. Summary Treatment Planning
Root canal therapy is indicated in situations in which the pulp cannot recover:
Irreversible pulpitis
Pulpal necrosis

95. 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