Endodontic Diagnosis and Treatment Planning

Endodontic diagnosis could be a difficult task in most occasions, but with clinical assessment and careful history taking this task would be easier and clearer.
This lecture assembled by Osama Asadi, B.D.S, concentrating at the basic science of diagnosing pulpal and periapical diseases and their differential diagnosis and treatment plan. also endodontic case sheet and review-cases attached to the lecture at the end to help proper understanding of the subject.

1. Endodontic Diagnosis and Treatment Planning Dr. Osama Asadi , B.D.S Information provided here are collected from several evidence-based academic textbooks well-known throughout the world like Elsevier publications and others

2. Case presentation Pain Swelling Fistula Tooth discoloration Broken tooth

3. Pain Swelling abcess abcess Fistula Tooth Discoloration Broken Teeth

4. Clinical Tests Cold test Heat test Electrical pulp test Cavity test Pulp Tests Periapical Tests Palpation Percussion

5. Cold Test Apply ice on the cervical third of the tooth where enamel is thin. Normal Pulp: response, last for 1-3 seconds Pulpitis: response, last for minutes Necrotic pulp: No response

6. Heat Test Heat Gutta-percha and place it on cervical third of the tooth where enamel is thinnest. Normal Pulp: response, last for 1-3 seconds Pulpitis: response, last for minutes Necrotic pulp: No response

7. Palpation Place the index finger on the periapical area of the tooth with firm gentle pressure. Normal Periapical: No response Inflamed: response with pain at that area

8. Percussion Place index finger on the incisal edge / occlusal third of the tooth and push inward with gentle pressure. Normal Periapical: No response Inflamed: response with pain

9. Pulpal and Periapical Conditions / Diagnosis Normal Pulp Reversible Pulpitis Irreversible pulpitis Necrotic Pulp Apical Periodontitis Acute Apical Abscess Chronic Apical Abscess Condensing Osteitis

10. Normal Pulp Normal pulp is symptom-free as reported by the patient. Response to cold testing and effect lasts only for 1-2 seconds then disappear. Response normally to electrical pulp testing. Radiographically show normal PDL space and intact lamina dura.

11. Reversible Pulpitis Symptoms Discomfort or pain on sweet / cold food and beverages It last for few seconds then relieved. Pain never spontaneous Tests Cold test : response positively, enough for diagnosis Electrical pulp test: response positively. Radiograph Intact lamina dura Normal PDL space Normal periapical area

12. Irreversible Pulpitis Symptoms Spontaneous Sharp pain Last for minutes or hours. Poorly localized referred pain Interfere with patient sleep Aggravated by hot , relieved by cold. Over-the-counter analgesics is ineffective Tests Heat test : response positively, enough for diagnosis Cavity test: if open caries, response positively. Radiograph Slight widening of PDL space Periapical radiolucency present only if infection has passed the apical foramen.

13. Necrotic Pulp Symptoms Asymptomatic History of pulpitis or trauma Discoloration of tooth may present Tests Response negatively to thermal and electrical pulp tests. Response positively to percussion or palpation if only apical infection present. Radiograph Intact lamina dura Slight widening of PDL space. Periapical radiolucency present only if infection has passed the apical foramen.

14. Apical Periodontitis Symptoms Pain on biting and mastication Tests Percussion / Palpation: response positively. Radiograph Slight widening of PDL space may or may not present. Periapical radiolucency may or may not present

15. Acute Apical Abscess Symptoms Spontaneous pain Tenderness of tooth to biting Swelling of apical area and pus formation Fever, malaise, and lymphadenopathy may be reported Tests Percussion / Palpation: response positively. Radiograph Slight widening of PDL space may or may not present. Periapical radiolucency may or may not present

16. Chronic Apical Abscess Symptoms Little or no discomfort / pain Tenderness of tooth to pressure Swelling of apical area and pus formation Tests Percussion / Palpation: response positively. Radiograph Slight widening of PDL space may or may not present. Periapical radiolucency.

17. Condensing Osteitis Radiograph Radiopaque lesion at the apex.

18. Treatment Plan Reversible pulpitis , treated by removing the offending stimulus. Irreversible pulpitis , treated by RCT Apical Periodontitis , treated by RCT Apical Abscess , treated by RCT As it seen, reaching a definitive diagnosis could be a challenge but the result is the same, RCT!

19. Appendix Endodontics Case Sheet Clinical Cases for review References

20. Endodontic Case Sheet

21. Clinical Cases for review Case 1. Mandibular right first molar had been hypersensitive to cold and sweets over the past few months but the symptoms have subsided. Now there is no response to thermal testing and there is tenderness to biting and pain to percussion. Radiographically, there are diffuse radiopacities around the root apices. Diagnosis: Pulp necrosis; apical periodontitis with condensing osteitis. Tx : Root canal treatment (RCT)

22. Case 2. Following the placement of a full gold crown on the maxillary right second molar, the patient complained of sensitivity to both hot and cold liquids; now the discomfort is spontaneous. Upon application of Endo-Ice® on this tooth, the patient experienced pain and upon removal of the stimulus, the discomfort lingered for 12 seconds. Responses to both percussion and palpation were normal; radiographically, there was no evidence of osseous changes. Diagnosis: Irreversible pulpitis; normal apical tissues. Tx : Root canal Treatment (RCT)

23. Case 3. Maxillary left first molar has occlusal-mesial caries and the patient has been complaining of sensitivity to sweets and to cold liquids. There is no discomfort to biting or percussion. The tooth is hyper-responsive to Endo-Ice® with no lingering pain. Diagnosis: reversible pulpitis; normal apical tissues. Tx : Removal of offending stimulus. Applying dentin desensitizer on exposed dentinal tubules.

24. References Arnaldo Castellucci , MD, DDS. Endodontics, Volume 1, Pulpal diseases p. 139-156. American Association of Endodontics, Endodontics: Colleagues for Excellence, Endodontic Diagnosis (2013 issue).

25. Thanks for reading!