endodontic diagnosis and treatment planning with recent advancements

presentation on endodontic diagnosis and treatment planning and advancements of diagnosis

1. GOOD MORNING!

2. Tittle - JOURNAL CLUB PRESENTATION ON ENDODONTIC DIAGNOSIS Name of Presenter- DR KUSUM MEENA Department: CONSERVATIVE DENTISTRY & ENDOODNTICS MAHATMA GANDHI DENTAL COLLEGE & HOSPITAL A unit of Mahatma Gandhi University of Medical Sciences & Technology

3. ENDODONTIC DIAGNOSIS “listen to your patient...The patient will give you the diagnosis”

4. INTRODUCTION 01 CHIEF COMPLAINT 02 HISTORY AND CASE RECORDS 03 EXAMINATION AND TESTING 04 CONCLUSION AND REFRENCES 05 CONTENTS

5. INTRODUCTION “Correct treatment begins with a correct diagnosis.” DIAGNOSIS:- It is the correct determination,discriminative estimation & logical appraisal of conditions found during examination as evidenced by distinctive signs,marks and symptoms.

6. ‘the determination of the nature of a disease made from a study of the signs and symptoms of a disease.’’ -Stedman’s Medical Dictionary Diagnosis is the art and science of detecting and distinguishing deviations from health and the cause and nature thereof. -GROSSMAN’s 15th edition

7. ENDODONTIC TRIAD TRADITIONAL CONTEMPORARY DEBRIDEMENT APICAL SEAL STERILIZATION DIAGNOSIS ANATOMY AND DEBRIDEMENT 3D OBTURATION SUCCESS SUCCESS

8. CHIEF COMPLAINT “ T he patient’s reason for seeking care or attention, expressed in terms as close as possible to those used by the patient or responsible informant” In order to ascertain a correct diagnosis, the patient’s chief complaint should be properly documented, using the patient’s own words.

9. MEDICAL HISTORY Clinician is responsible for taking a proper medical history from every patient . Any patient “of record” should be questioned at each treatment visit . Hepatitis B , HIV , and other STDs , as well as active oral infections, may be passed from the patient to the dentist or auxiliary. Baseline blood pressure and pulse should be recorded for a patient at each treatment visit.

10. Clinical presentations that mimic oral pathologic lesions Examples: Tuberculosis involvement of the cervical and submandibular lymph nodes-- misdiagnosed -- lymph node enlargement as a result of an odontogenic infection Patients with anemia frequently exhibit paresthesia of the oral soft tissues.

11. Radiation therapy to the head and neck region can result in increased sensitivity of the teeth and osteoradionecrosis Acute maxillary sinusitis may create diagnostic confusion because it may mimic tooth pain in the maxillary posterior quadrant.

12. Uncontrolled diabetes mellitus respond poorly to dental treatment and may exhibit recurring abscesses— misdiagnosed -- abscesses of dental origin. Sickle cell anemia has the complicating factor of bone pain— mimics -- odontogenic pain and loss of trabecular bone pattern on radiographs— confused -- with radiographic lesions of endodontic origin. If at the completion of a thorough dental examination, the subjective, objective, clinical testing, and radiographic findings - do not result in a diagnosis with an obvious dental etiology , then consideration must be given that an existing medical problem could be the true etiology

13. DENTAL HISTORY Chronology of events that lead up to the chief complaint is recorded as the dental history. Help guide the clinician as to which diagnostic tests are to be performed. The history should include any past and present symptoms , as well as any procedures or trauma that might have evoked the chief complaint.

14. HISTORY OF PRESENT DENTAL PROBLEM Dialogue between the patient and the clinician should encompass all of the details pertinent to the events that led upto the chief complaint. Interview first determines what is going on in an effort to determine why is it going on for the purpose of eventually determining what is necessary for the resolution of the chief complaint.

15. DENTAL HISTORY INTERVIEW PROVOCATION AND ATTENUATION LOCALIZATION INTENSITY AND DURATION COMMENCEMENT

16. LOCALIZATION Localization allows subsequent diagnostic tests to focus more on a particular tooth. Not well localized, the diagnosis is a greater challenge. Proprioceptors are prevalent in the periodontal ligament spaces (than dental pulp)- This is why it may be difficult to discriminate the location of dental pain in the earlier stages of pathosis Can you point to the offending tooth?”

17. COMMENCEMENT “When did the symptoms first occur?” Initiating event: May be spontaneous in nature May have begun after a dental visit for a restoration Trauma may be the etiology Possible clinical presentation; -High points Possible clinical presentation; -Symptomatic irreversible pulpitis - Fractured tooth Biting on a hard object may have initially produced the symptoms. May have occurred concurrently with other symptoms like sinusitis, headache, chest pain, etc. Possible clinical presentation; -Symptomatic apical periodontitis - Crack tooth syndrome - Referred pain

18. INTENSITY “How intense is the pain?” Clinician might ask, “On a scale from 1 to 10, with 10 the most severe, how would you rate your symptoms?”

19. DURATION “Do the symptoms subside shortly, or do they linger after they are provoked?” Difference between a cold sensitivity that subsides in seconds and one that subsides in minutes may determine whether a clinician repairs a defective restoration or provides endodontic treatment.

20. PROVOCATION AND RELIEF OF PAIN What produces or reduces the symptoms?” Mastication and locally applied temperature changes Only on palpating that area Drinking something cold or hot Chewing or biting is the only stimulus that “makes it hurt” Possible clinical presentation; -Symptomatic apical periodontitis -Irreversible pulpitis -Dentinal hypersensitivity Possible clinical presentation; -Apical abcess or cyst -Localized periodontitis Possible clinical presentation; -Reversible pulpitis -Dentin hypersensitivity Possible clinical presentation; -Crack or fractured tooth -Apical periodontitis Might say that the pain is only reproduced on “release from biting.” Possible clinical presentation; -Crack tooth syndrome

21. CLINICAL EXAMINATION 1.EXTRA ORAL EXAMINATION 2.INTRA ORAL EXAMINATION

22. INTRA ORAL EXAMINATION

23. VISIUAL INSPECTION COLOUR-1) Discoloured opaque= inflamed, degenrated or necrotic pulp 2) calcified canal = Light yellow hue of the crown 3) pink tooth = indicates internal resorption Crown contour- wear facets,Fractures and Restorations

24. INTRAORAL SINUS TRACTS 1) C hronic endodontic infection will drain through an intraoral communication to the gingival surface and is known as a sinus tract. 2) S ometimes lined with epithelium , extends directly from the source of the infection to a surface opening, or stoma 3) M ost sinus tracts are not lined with epithelium throughout their entire length. 4) The stoma of the sinus tract may be located directly adjacent to or at a distant site from the infection. To locate the source of an infection, the sinus tract can be traced by threading the stoma with a gutta-percha point.

25. PULP TESTING It does not indicate :that the tooth is vital or nonvital but is rather an indication of inflammation in the periodontal ligament The contralateral tooth should first be tested as a control, as should several adjacent teeth that are certain to respond normally. performed by applying firm digital pressure to the mucosa covering the roots and apices. A positive response: to palpation may indicate an active periradicular inflammatory process. PERCUSSION PALPATION

26. carried out by sounding or walking the probe around the tooth, while pressing gently on the floor of the sulcus. Horizontal bone loss with generalized pocket is not as worrisome as isolated vertical bone loss which frequently indicates vertical root fracture MOBILITY Grade I – Noticeable horizontal movement in its socket. Grade II – within 1 mm of horizontal movement. Grade III – Horizontal movement greater than 1 mm and/or vertical depressibility. PERIODONTAL PROBING

27. BITE TEST T he bite test is useful in identifying a cracked tooth or fractured cusp when pressure is applied in a certain direction to one cusp or section of the tooth. Also useful in diagnosing pulpal pathosis when it has extended into the periradicular region The Tooth Slooth and the Frac finder are the popular commercially available devices for the bite test

28. TRANSILLUMINATION It is useful test in detection of caries, calculus and soft tissue lesions. Primarily used to help determine the presence of crown or root fracture. Can also be used in determination of pulp vitality. E.g. Fibroptic illumination.

29. PULP TEST - rely on sensory fibers THERMAL -COLD -HEAT 2. ELECTRIC SENSIBILITY TEST - rely on intact vasculature LASER DOPPLER FLOWMETRY PULSE OXIMETRY ACCESORY TESTS VITALITY TEST Quantitative evaluation of the status of pulp tissue can only be determined histologically

30. PULP SENSIBILITY TEST 1.COLD TESTING Cold is the primary pulp testing method for many clinicians Useful for patients with porcelain jacket crowns or PFM crowns To perform test with sticks of ice – use of rubber dam is must to avoid false-positive response

31. AGENTS- DDM ( Dichlorodifluoromethan )= -15°C SOLID CO2 / DRY ICE / CO2 STICK = -78°C ETHYL CHLORIDE (SKIN REFRIGERANT)= -41°C GREEN ENDO ICE (1,1,1,2 tetra fluoro ethane)= -26.2 °C Establish base line response- testing adjacent and contralateral teeth first Isloate teeth Agent application Site- mid facial area with #2 cotton pellet Duration- maximum 15 sec

32. 2. Heat test Useful when a patient’s chief complaint is - Intense dental pain on contact with any hot liquid or food - Unable to identify which tooth is sensitive Often a tooth that is sensitive to heat may also be responsible for some spontaneous pain- patient may present with cold liquids in hand just to minimize the pain

33. AGENTS- HOT GUTTA PERCHA HOT COMPOUND MATERIAL HOT BURNISHER RUBBER WHEELS BURLEW DISC Temperature of melting gutta percha used in pulp testing is approximately 78 ◦C But it has been reported to be up to 150 ◦C Red hot 60°C

34. ELECTRIC PULP TEST Works on the premise that electrical stimuli cause an ionic change across the neural membrane, thereby inducing an action potential with a rapid hopping action at the nodes of Ranvier in myelinated nerves Pathway for the electric current is from the probe tip of the test device to the tooth -along the lines of the enamel prisms and dentine tubules, and then through the pulp tissue

35. A “tingling” or “warming” sensation will be felt by the patient once the increasing voltage reaches the pain threshold Threshold level varies between patients and teeth, and is affected by factors such as individual age, pain perception, tooth surface conduction, and resistance

36. EPT probe tip placed flat against the contact area , and having a conducting medium such as toothpaste between the probe tip and the tooth surface is essential Placing the probe tip labially within the incisal or occlusal two-thirds of the crown gave more consistent results

37. FALSE NEGATIVE RESULTS- Healthy immature teeth (it may take up to five years before the maximum number of myelinated fibres reaches the pulp-dentine border at the plexus of Rashkow ) Pulp canal calcification Primary hyperthyroidism patient frequently have an increased sensory response threshold to EPT. Healthy pulps undergoing orthodontic treatment Recently traumatised teeth undergoing pulp repair

38. FALSE POSITIVE RESULTS- Two adjacent teeth have contacting proximal metallic restorations Ineffective tooth isolation Breakdown products from pulps undergoing necrosis Remnants of inflamed pulp tissues

39. Clinical Interpretations of Pulpal Response to EPT Normal response: A positive response is a response that occurs at the same neural excitation threshold as the control tooth Negative response: This denotes a nonvital tooth, which fails to respond even when the tester is set to the highest electrical excitation value. Early response: This denotes a diseased state of pulp as the tooth responds to a threshold which is less than that of the control tooth. Delayed response: This also denotes a diseased state of the pulp wherein the tooth responds at a significantly higher electrical excitation level compared to the control tooth.

40. PULP VITALITY TEST 1. LASER DOPPLER FLOWMETERY Used to assess blood flow in microvascular system Laser light is transmitted to the pulp by means of a fiber optic probe Uses Helium Neon ( HeNe ) and Gallium Aluminum ( Ga AlAs ) as semiconductor diode lasers at a power of 1 to 2 mW . Wave length of the HeNe laser is 632.8nm and that of the semiconductor diode laser is 780 to 820nm

41. The end of the LDF which contacts the tooth contains both sending and receiving optic fibers , with one of the configuration being one source and two detectors in a triangular arrangement at the probe end The ideal position to place the probe is 2 to 3 mm from the gingival margin

42. Advantages Allows painless diagnosis - Useful for the vital or non vital diagnosis of immature or traumatized teeth - Continuous and instantaneous reflection of flow changes Disadvantages - Detect only the coronal blood flow of the pulp (which may not relate to the actual blood flow on the linear scale ) - Not useful in teeth with crowns and large restorations

43. Doppler principle - light beam’s frequency will shift by moving red blood cells but will remain unshifted as it passes through static tissue. The average Doppler frequency shift will measure the velocity at which the red blood cells are moving. LIMITATIONS:- 1. Not useful in teeth with crowns and large restorations 2. Detect only the coronal blood flow of the pulp, which may not relate to the actual blood flow on the linear scale.

44. PULSE OXIMETRY Non invasive oxygen saturation monitoring device widely used in medical practice for recording blood oxygen saturation level during administration of IV anesthesia through the use of finger, foot and earlobe Probe is placed on the labial surface of the tooth crown and the sensor on the palatal surface. Ideal placement of the probe is in the middle third of the crown

45. Probe containing two LEDs: Red light-660 nm & Infrared light (900–940 nm) Measures absorption of oxygenated and deoxygenated Hb Received by a photodetector diode connected to a microprocessor. Relationship between the pulsatile change in the absorption of red light & infrared light : Assessed by the oximeter + known absorption curves for oxygenated and deoxygenated hemoglobin

46. Indications: Recent trauma Primary & immature permanent teeth Patient monitoring: sedation L imitations: Intrinsic interference: venous blood & tissue constituents, acidity, CO2 Extrinsic interference Well adapting sensor Hb bound to other gases Extensive restorations

47. ACCESORY TESTS Photoplethysmography Ultraviolet light/ Fiberoptic Fluorescent SpectrometryTransmitted Laser Light (TLL) Dual Wavelength Spectrophotometry Ultrasonic Doppler Imaging

48. EXTRA ORAL EXAMINATION Basic diagnostic protocol suggests that a clinician observe patients as they enter the operatory Visual and palpation examinations of the face and neck are warranted to determine whether swelling is present Facial asymmetry can be summarized and divided into three main categories, Congenital (originating prenatally) Developmental (arising during growth with inconspicuous etiology) Acquired (resulting from injury or disease) Hemifacial atrophy

49. Palpation of the cervical and submandibular lymph nodes - integral part of the examination protocol found to be firm and tender, facial swelling, elevated temperature - high probability that an infection is present Lymph nodes which should be palpated are: Auricular Post auricular Submental Submandibular Supraclavicular Deep cervical

50. Method of palpation: Bilateral palpation= done to differentiate between symmetrical structures on both side of face Pretragus palpation= ask patient to slowly open and close mouth while the clinician bilaterally palpates pretragus depression with his/her index finger

51. EXTRA ORAL SINUS TRACTS Sinus tracts of odontogenic origin may also open through the skin of the face Site - usually anatomically close to the causative tooth Openings in the skin will generally close once the offending tooth is treated and healing occurs

52. RADIOGRAPHS The radiograph is one of the most important clinical tools in making a diagnosis. It permits visual examination of the oral structures that would otherwise be unseen by the naked eye. Without it, diagnosis, case selection, treatment, and evaluation of healing would be impossible

53. Radiographs may show the number, course, shape, length, and width of root canal  The presence of calcified material in the pulp chamber or root canal  The resorption of dentin originating within the root canal (internal resorption) or from the root surface (external resorption)  Calcification or obliteration of the pulp cavity  Thickening of the periodontal ligament  Resorption of cementum, and nature and extent of periapical and alveolar bone destruction

54. LIMITATIONS Radiograph is a 2-D representation of a 3-D object. Radiographic misdiagnosis – if there is only buccal/ cervical involvement (deep caries)  Besides diagnostic radiograph, additional radiographs are necessary depending on specific situations. This can be overcome by the tube shift technique, in which two films are taken in same vertical angulation and 10 - 15º change in horizontal angulation. This projection helps to Superimposed canals can be separated , Locate perforations , Lesions that appear attached to the root will move away when the projection is changed

55. CONE BEAM COMPUTED TOMOGRAPHY The introduction of cone beam computed tomography (CBCT) or cone beam volumetric tomography (CBVT) imaging facilitated the transition from 2D to a 3D approach in image acquisition and interpretation The device utilizes a cone-shaped beam of ionizing radiation , which passes through the center of the region of interest  The image is captured as three-dimensional pixels termed voxels with a resolution ranging from 0.4 mm to 0.076 mm  According to Scarfe et al, the following are the steps involved in CBCT image processing are - Acquisition configuration Image detection  Image reconstruction Image display

56. Digital Imaging System "radio" component consists of a high- resolution sensor with an active area that is similar in size to conventional film. "visio" portion, consists of a video monitor and display-processing unit . T he image is digitized and stored by the computer. The unit magnifies the image , can produce colored images and display multiple images simultaneously. further manipulation of the image is possible ; i.e; enhancement, contrast stretching, and reversing. A zoom feature is also available to enlarge a portion of the image.In addition, a digital intraoral camera can be integrated with most systems.

57. Other new technology Ultras ound Magnetic resonance Imaging (MRI) Radioisotope imaging  Plathesmography Crown surface tepreture Xeroradiography  Computed tomography (CT) Direct Subtraction radiography.

58. CONCLUSION The assesment of pulp is crucial diagnostic procedure. The endodontic examinations hould be performed and the results recorded before initiating any dental procedure. Reliable information serves to improve diagnostics, treatment planning and patient communication. A diagnosis can only be reached once all the information has been gathered and assessed.

59. REFERENCES

60. THANK YOU FOR YOUR LISTENING THANK YOU! . ‘‘FOR I SEEK THE TRUTH BY WHICH NO MAN HAS EVER BEEN HARMED.’’ —MARCUS AURELIUS, MEDITATIONS VI. 21, 173 AD