2 endodontic-diagnosis-and-treatment-planning-slides.pptx

oral health

1. Endodontic Diagnosis
and Treatment

Planning

2. Overview

= The journey to definitive treatment begin with accurate
diagnosis.

= However, accurate diagnosis is not always possible, due
to complexity of the symptoms and many diseases share
the same signs and symptoms.

= Also it established that histological condition of the pulp
does not always relates to the sign and symptoms.

The basic steps in diagnostic procedure are:
= Chief complaint
= History (medical and dental)
= Oral examination
= Clinical tests
= Data analysis and differential diagnosis
= Treatment plan

(© iraqi Dental Academy a @lraqiDental

3. Overview

There are limited numbers of possible diagnosis for pulpal
and periapical conditions, that includes:

Pulpal diagnosis:
= Normal
= Reversible pulpitis
a Irreversible pulpitis (symptomatic/ asymptomatic)
= necrosis
Periapical diagnosis:
= Normal
= Symptomatic apical periodontitis
= Asymptomatic apical periodontitis
= Acute apical abscess
= Chronic apical abscess
= Condensing osteitis
These will be discussed at the end of the slides

Iraqi Dental Academy @ @lraqiDental

4. Chief Complaint

= This is the first information that volunteered by the
patient and should be recorded in the exact formula.

a It can help in both diagnosis and treatment plan
because these comments are direct and non-biased.

Iraqi Dental Academy @ @lraqiDental

5. Dental History

= Investigate past dental history for recent trauma, recent
restoration or periodontal treatment, and previous
treatment for TMJ dysfunction.

f Iraqi Dental Academy @ (OlraqiDental

6. Dental History Interview

= The dentist should interview (ask) the patient about the
symptoms he has to get the full idea of ‘what’ is
happening and ‘why’ it is happening.

Patient may complain from:
= Pain
= swelling
= Sinus tract
= Broken tooth
m Loose tooth
= Tooth discoloration
= Bad taste

© iraqi Dental Academy @ (OlraqiDental

7. Dental History Interview

If patient complain of pain, ask him the following questions:

= When did pain begin?

= Where is the pain located?

= Is the pain always in the same place?

= What is the character of the pain (short, sharp, long,
lasting, dull, throbbing, continuous, occasional)?

= Doses the pain prevent sleeping or working?

= Is the pain worse in the morning?

= Is the pain worse when you lie down?

= Did or does anything initiate the pain (trauma, biting,
thermal)?

= Once initiated, how long does the pain Last?

= Is the pain continuous, spontaneous or intermittent?

= Does anything make the pain worse (hot, cold, biting)?
Does anything make the pain better (cold, analgesics)?

© Iraqi Dental Academy @ @lraqiDental

8. Dental History Interview

Similarly, if patient is presented with swelling, take
history of:

= When did the swelling begin?

= How quickly has the swelling increased in size?

= Where is the swelling located?

= What is the nature of the swelling (soft, hard, tender)?
= Is there drainage from the swelling?

u Is the swelling associated with loose or tender tooth?

Af iraqi Dental Academy @ (OlraqiDental

9. What Indicate a Difficult Diagnosis?

The following presentations may indicate a case that is
difficult diagnositically:

= Patient can not Localize the pain source

= No local dental cause for the pain can be identified (no
caries, no restoration, etc..)

= Pain is spontaneous or intermittent

= Stimulation of suspected tooth (using vitality tests) does
not produce symptoms

= More than one tooth is suspected

= Symptoms are bilateral

= Selective anesthesia fail to Localize the source of pain

© Iraqi Dental Academy ® @lraqiDental

10. Extra-oral Examination

= Clinician should Look and analyze the patient as soon as
he enter the room.

= Look for general appearance, skin tone, facial
asymmetry, swelling, discoloration, redness, extraoral
scars, sinus tracts and lymphadenopathy.

= Palpation of face and neck area is also important, to
check for swelling or tenderness. Many times these
swelling are not clear visually, and require palpation to
identify.

= Palpation of cervical and submandibular lymph nodes is
important part of diagnostic procedure. If there is
swelling or feels firm and tender, with elevated
temperature, then these is greater chance of systemic
involvement.

(© iraqi Dental Academy a (OlragiDental

11. Extra-oral Examination

= Loss of definition of nasolabial fold on one side of the
nose may be the earliest sign of canine space infection.
This can result from infected maxillary canine, or long-
rooted incisors.

FF iraqi Dental Academy « @lraqiDental

12. Intra-Oral Examination

= Oral tissue is dried and examination begin of the Lips,
oral mucosa, cheeks, tongue, periodontium, gingiva,
palate and muscles.

= Look for any sign of discoloration, inflammation,
ulceration, and sinus tract formation.

= Sinus tract can be traced to its source using gutta-percha
points size #25 or #30 and inserted into the opening until
resistance is felt. It may cause slight discomfort to the
patient.

= Examine teeth with mirror and explorer and look for
discoloration, fracture, abrasion, attrition, erosion, caries,
defective restoration, or other abnormalities.

= A discolored crown can be an indication of pulp pathosis.

Af iraqi Dental Academy a (OlraqiDental

13. Periodontal Examination

Mobility

= Examine mobility of the tooth by placing the back end of
mirrors on both buccal and Lingual surface of the tooth,
then apply pressure in bucco-lingual direction and also
in vertical direction. Any movement more than 1mm
should be considered abnormal.

= Increased mobility does not mean the pulp is not vital,
mobility is an indicative of the status of the periodontal
attachment.

= Increased mobility can occur due to trauma, occlusal
prematurities, rapid orthodontic movement,
parafunctional habits, periodontal diseases, root fracture
or pulpal diseases.

Bf Iraqi Dental Academy a @lraqiDental

14. Periodontal Examination

Probing

= Probing is an important step in diagnosis. Teeth with
wide periodontal pocket usually are periodontal in origin,
while teeth with narrow Localized pocket are usually
endodontic in origin, or could be vertical root fracture.

= Furcation bone loss could be periodontal or endodontic
in origin, and should be recorded in the chart.

© iraqi Dental Academy @ @lraqiDental

15. Clinical Tests

These include:

= Palpation

= percussion

= Thermal tests

= Electric pulp test

= Bite test

= Test cavity

= Staining and transillumination
= Selective anesthesia

= These has been discussed extensively in previous
lectures, however, a short overview will be presented
here.

FF Iraqi Dental Academy en @lraqiDental

16. Palpation

= Firm digital pressure with index finger is applied to the
apical area of the tooth, and adjacent teeth.

= Any soft tissue swelling, bony expansion should be
noted and recorded.

= Pain or tenderness during the procedure should be
recorded too.

= This may indicate an active periapical inflammation,

however, it does not determine whether it is endodontic
or periodontal in origin.

© iraqi Dental Academy a (OlraqiDental

18. Percussion

= This test is performed when the patient complain of
pain during biting or mastication.

= Pressure is applied with index finger on the incisal/
occlusal surface of the tooth vertically and horizontally.

= The adjacent teeth should be tested first to serve as
control and to know the normal response of the patient.

ı If patient does not report any pain after completing this
test, then a blunt instrument is used to tap on the tooth.

= This test does not indicate the status of the pulp, rather
it indicate presence of inflammation in the PDL.

Iraqi Dental Academy @ @lraqiDental

20. Thermal Tests

= These include cold test, and heat test.

= Cold test can be used with ice sticks, dry ice (co2), or
refrigerant spray.

= Adjacent teeth should be isolated with gauze to prevent
false-positive results, then cold instrument is applied to
the tooth surface and response is waited.

= If patient response to the test and pain subside after
removal of the instrument then the pulp is normal.

= If pain does not diminish or rather increase after
removal of the instrument then this tooth most likely
has a pulpal pathosis.

Af Iraqi Dental Academy e (OlraqiDental

21. Thermal Tests

= Heat test can be applied using heated water with
syringe (after isolation with rubber dam), heated gutta-
percha (remember to add lubricant to the tooth surface
to prevent adhesion of gutta-percha to the tooth), or the
use of rotating rubber cup (not recommended).

= Cold test has been reported to be equal or even
superior to electrical pulp testing according to several
studies.

Iraqi Dental Academy ® (OlraqiDental

23. Electrical Pulp Test

= This test does not indicate the presence of vascular
supply in the pulp (a sign of vitality), but rather indicate
the presence of intact nerve fibers.

= It has been reported that electrical pulp testing is most
accurate when detecting necrotic teeth.

= Some studies has been reported that cold test has
superior advantage over electrical test, while some
studies reported no significant difference between the
two tests.

Iraqi Dental Academy “ (OlragiDental

25. Bite Test

= It begin by applying firm pressure using cotton tip
applicator, toothpick, or tooth slooth on each cusp of
the tooth.

= Patient will report pain when there is apical pathology
or root fracture.

= Sometimes patient feel pain when the instrument is
removed, which may indicate a fractured tooth or root.

© iraqi Dental Academy ® @lraqiDental

27. Test Cavity

= This test is not recommended because it is an invasive
procedure.

= It only used when other test results failed to determine
the condition of the pulp.

= A bur in high speed with water coolant is used to drill
the tooth, when dentin is reached the patient will feel
pain which indicate vital pulp tissue.

= However, when no pain is felt then the tooth is necrotic
and the procedure is continued to access opening and
further endodontic treatment.

FF iraqi Dental Academy a @lraqiDental

28. Staining and Transillumination

= Stains can be used to determine the presence of fracture
in the root.

= Also tranillumination with strong fiberoptic light can
determine the fracture site.

= Area that is close to the light source will appear bright,
while area beyond the fracture will appear dim.

Iraqi Dental Academy @ (OlraqiDental

30. Selective Anesthesia

= It used when other tests are inconclusive. PDL injection
is applied to each tooth, starting from the maxilla then
mandibule

= A most posterior tooth should be anesthetized first and
progressing anteriorly.

u If all teeth in maxilla anesthetized and pain is still
present, the same procedure is applied to the mandible
until pain disappear.

= However, it should noted that PDL injection can
anesthetize more than one tooth at a time which make
it less useful in determining which tooth is the source of
pain.

= Therefore, this technique is most useful in recognizing
which arch (maxilla or madibule) is the source, and not a
specific tooth.

© Iraqi Dental Academy a @lraqiDental

31. Radiographic Examination

= The value of radiographic image are sometimes
overestimated by the clinician. Proper diagnosis and
clinical tests are necessary, and radiograph is only
supplementary.

= Traditional radiography is two-dimensional presentation
of three-dimensional structures, therefore multiple
radiograph should be taken from different angles to
visualize more hidden structures.

= A well-prepared radiograph can find multiple canals,
multiple roots, resorption, caries, defective restoration,
root fracture and state of root maturation and apical
development.

© Iraqi Dental Academy a @lraqiDental

32. Radiographic Examination

Periapical pathology can be presented radiographically
with:

= The lamina dura is absent apically

= Radiolucency at the apex

= However, not all apical pathosis are seen on radiograph,
especially early lesions.

= Studies has found that radiolucency on radiograph can
be seen only when pathosis reach the cortical bone, it
can not be seen when presented in cancellous bone.

= The root apecies of most anterior and premolars are
close to the cortical bone, therefore seen early. While
molar teeth are found in the cancellous bone, therefore
not seen early in the radiograph.

Iraqi Dental Academy a @lraqiDental

33. Radiographic Examination

= Absence of radiolucency in the the radiograph does not
mean there is no pathology, other clinical tests should
be performed to reach that level of diagnosis.

= Lamina dura is the most consistent radiographic finding
when tooth is not vital. If lamina dura is widened, or
intermitted then it can be an indication of pulpal
pathosis.

= In addition to that, radiograph can shows presence of
pulp calcifiction, or canal obliteration due to dentin
formation, and these conditions are normal and need no
intervention unless pulp is offended.

a It worth mentioning that more advance radiographic has
been incorporated in dental practice in recent years with
superior imagining qualities compared to conventional
2D radiograph.

(© iraqi Dental Academy ® @lraqiDental

35. Normal pulp

= The tooth response normally to pulp tests.

= It response with pain to the tests when applied and pain
is disappear after removal of the stimuli.

Iraqi Dental Academy @ @lraqiDental

36. Reversible Pulpitis

a It mean that the pulp is inflammed but the condition is
reversible.

= Pulp return to normal after removal of the cause.

= It usually presented with caries, defective restoration,
exposed dentin, recent periodontal treatment.

Treatment

= The offending stimuli should be removed, and the tooth
is restored.

= In case of deep caries, direct pulp capping technique is
applied.

Iraqi Dental Academy @ @lraqiDental

37. Irreversible Pulpitis

= The pulp is inflammed beyond repair.

= It can be subdivided into two categorizes: symptomatic
and asymptomatic.

Symptomatic Irreversible Pulpitis

= The pain usually spontaneous or intermittent.

= Response rapidly to thermal stimuli and pain persist
even after removal of the stimuli.

= The pain could be sharp, dull, localized, diffuse or
referred.

= Radiographically, it can be presented with widened PDL,
however, sometimes no sign of pathology can be seen.

Iraqi Dental Academy @ @lraqiDental

38. Irreversible Pulpitis

Symptomatic Irreversible Pulpitis (continued):

= When the patient presented with symptoms of
symptomatic irreversible pulpitis in anterior teeth
without any sign of caries or local factor, the patient
should be ask of past history of general anesthesia or
endotracheal intubation procedures.

m He also should be ask about any history of orthodontic
treatment.

Treatment

= Root canal treatment

({ iraqi Dental Academy 6) (OlraqiDental

39. Irreversible Pulpitis

Asymptomatic Irreversible Pulpitis

= In this case, even that the tooth is presented with deep
caries or apical or lateral radiolucency the patient
complain of no symptoms.

Treatment

= RCT should be done for this tooth as soon as possible so
that it do not convert to symptomatic pulpitis or future
necrosis occur with lingering pain.

FF iraqi Dental Academy e (OlraqiDental

40. Pulp Necrosis

= The pulp is dead and RCT is indicated.

= Tooth does not respond to electrical or cold test,
however it may response to heat test if applied for long
time.

= Thickened PDL can be seen on the radiograph.
= When necrosis is chronic the infection reach the

periapical area and lead to apical pathosis which
presented as radiolucency at the apex.

Iraqi Dental Academy @ @lraqiDental

41. Symptomatic Apical Periodontitis

= This condition is characterized by inflammation of
periodontal area of the infected tooth.

= The tooth response to biting, percussion or palpation
tests.

= The tooth may or may not response to vitality test.

= Radiographically, the tooth presented at least with
widened PDL. Apical radiolucency may or may not be
seen.

Treatment
a RCT

Iraqi Dental Academy @ @lraqiDental

42. Asymptomatic Apical Periodontitis

= The tooth usually does not response to vitality tests,
and does not response to biting test but it “feels
different”.

= The tooth usually exhibit apical radiolucency.

= However, patient does not complain of any symptoms

Treatment

a RCT

Af Iraqi Dental Academy @ @lraqiDental

43. Acute Apical AbScess

St ERY

= The patient complain of spontaneous pain, the tooth is
tender to biting, percussion and palpation test ,and
radiograph ranges from widened PDL to apical
radiolucency.

= Swelling of adjacent area is present and cervical and
submandibular lymph nodes usually tender to palpation.

Treatment

= Drainage of abscess if localized, and RCT.

FF iraqi Dental Academy @ @lraqiDental

44. Chronic Apical Abscess
= Patient presented with sinus tract with pus discharge,
with Little or no pain.

= Vitality test report no response, and tooth usually not
sensitive to biting test but “feels” different.

= Radiographically, apical radiolucency can be seen.

Treatment

= RCT. Sinus tract will resolve after few days to months
from endodontic treatment. If sinus tract is extraoral it
will leave a scar.

Iraqi Dental Academy @ (OlraqiDental

45. Condensing Ostietis

= The tooth present with apical Localized or diffuse apical
radiopacity.

= The tooth could be vital or non-vital.

Treatment

= It depend on the condition of the pulp.

= If pulp is normal then no treatment is required.

= If pulp is irreversibly inflammed then RCT is indicated.

= It should be noted that even with successful endodontic
treatment sometimes condesing ostietis does not
resolve (according to a study 50% does not resolve).
However, this can not present any problem to be
concerned about.

Iraqi Dental Academy a (OlraqiDental

46. References

= Endodontics principles and practice

= Cohen's pathways of pulp

( iraqi Dental Academy e @lraqiDental