The document discusses the process of diagnosis in endodontics. It emphasizes that an accurate diagnosis requires synthesizing

The document discusses the process of diagnosis in endodontics. It emphasizes that an accurate diagnosis requires synthesizing

1. Patient Evaluation, Diagnosis and Treatment Planning DR. RITIKA CHAUDHARY

2. INTRODUCTION Diagnosis is defined as the utilization of scientific knowledge to identify a diseased process and to differentiate it from other disease process.

3. PATIENT EVALUATION First step: Assemble all the available facts gathered from chief complaints, medical and dental history, diagnostic tests and investigations. Second step: Analyze and interpret the assembled clues to reach the tentative or provisional diagnosis. Third step: Make differential diagnosis of all possible diseases which are consistent with signs, symptoms and test results gathered. Fourth step: Select the closest, possible choice.

4. Case History The purpose of case history is to discover whether patient has any general or local condition that might alter the normal course of treatment. As with all courses of treatment, a comprehensive medical and previous dental history should be recorded. In addition, a description of the patient’s symptoms in his or her own words should be noted.

5. Chief Complaint It consists of information which promoted patient to visit a clinician. Symptoms are phenomenon or signs of deviation from normal and are indicative of illness. It should be recorded in patient’s own words.

6. History of Present Illness It should include signs and symptoms, duration, intensity of pain, relieving and exaggerating factors, etc. Examples of type of the questions: How long have you had the pain? Do you know which tooth is it? What initiates pain? How would you describe the pain? – Quality —Dull, sharp, throbbing, constant Location —Localized, diffuse, referred, radiating Duration —Seconds, minutes, hours, constant Onset —Stimulation required, intermittent, spontaneous Initiated —Cold, heat, palpation, percussion Relieved —Cold, heat, any medications, sleep

7. Dental History This helps to know any previous dental experience, and past restorations.

8. Medical History Allergies or Medication- Clinician must be informed about any allergy related to patient. For example, if the patient is allergic to local anesthetic during dental treatment, he/she may go in the state of anaphylactic shock. Allergic reactions may occur in the form of itching, rashes, swellings, gingivitis, ulcers, etc. Communicable Diseases- Evaluation of communicable diseases should be done cautiously as these can affect the management of the patient and can be transmissible. Clinician should seriously assesses the condition of a patient because of increasing incidence of AIDS and hepatitis B and C, so that proper measures can be taken. Systemic Diseases- Patients with valvular defects or heart murmurs are at high risk for development of bacterial endocarditis after surgical and dental procedures, therefore, prophylactic antibiotic coverage should be given to such patients before initiating dental treatment. Physiological Changes Associated with Aging- Changes in oral cavity occurring due to aging: • Attrition, abrasion and wear of proximal surfaces • Extrinsic staining • Edematous gingivae • Diminished salivary flow • Gingival recession.

9. Social Status of the Patient Social status of the patient is evaluated to know his attitudes, expectations, priorities, education, and habits. This helps in planning the line of treatment according to expectations of the patient.

10. EXAMINATION AND DIAGNOSIS Clinical examination: It includes both extraoral and intraoral examination. • Intraoral examination: It includes the examination of soft and hard tissue.

11. Clinical Examination Following sequence is followed during clinical examinations: Inspection Palpation Percussion Auscultation Exploration.

12. Inspection Before conducting intraoral examination, check the degree of mouth opening. For a normal patient, it should be at least two fingers. During intraoral examination, look at the following structures systematically: •The buccal, labial and alveolar mucosa The hard and soft palate The floor of the mouth and tongue The retromolar region The posterior pharyngeal wall and facial pillars The salivary gland and orifices.

13. Palpation After extraoral examination of head and neck region, one should go for extraoral palpation by use of fingers. If any localized swelling is present, then look for— • Local rise in temperature • Tenderness • Extent of lesion • Induration • Fixation to underlying tissues, etc. Palpation of salivary glands should be done extra-orally. Submandibular gland should be differentiated from lymph nodes in the submandibular region by bimanual palpation Palpation of TMJ can be done by standing in front of the patient and placing the index fingers in the preauricular region. The patient is asked to open the mouth and perform lateral excursion to notice Any restricted movement Deviation in movement Jerky movement Clicking Locking or crepitus.

14. Palpation of lymph nodes should be done to note any lymph node enlargement, tenderness, mobility and consistency. The lymph nodes frequently palpated are preauricular, submandibular, submental and cervical. Intraoral palpation is done using digital pressure to check any tenderness in soft tissue overlying suspected tooth. Sensitivity may indicate inflammation in periodontal ligament surrounding the affected tooth. Further palpation can tell any other information about fluctuation or fixation or induration of soft tissue, if any.

15. Percussion Percussion of tooth indicates inflammation in periodontal ligament which could be due to trauma, sinusitis and/or PDL disease. Percussion can be carried out by gentle tapping with gloved finger or blunt handle of mouth mirror. Each tooth should be percussed on all the surfaces of tooth until the patient is able to localize the tooth with pain. Degree of response to percussion is directly proportional to degree of inflammation.

16. Auscultation Auscultation is not of much importance, except in some cases. For example, auscultation of TMJ to check the clicking sound.

17. Exploration In this, clinical examination of the tooth is done by the use of explorer or probe.

18. Periodontal Evaluation Periodontal condition can be assessed by palpation, percussion, mobility of tooth and probing. Periodontal examination shows change in color, contour, form, density, level of attachment and bleeding tendency. A sulcus depth greater than 3 mm and the sites that bleed upon probing should be recorded in the patient’s chart. Mobility of a tooth is tested by placing a finger or blunt end of the instrument on either side of the crown and pushing it and assessing any movement with other finger. Classification of mobility Grade I: Slight (normal) Grade II: Horizontal tooth movement within a range of 1 mm. Grade III: Mobility more than 1 mm or when tooth can be depressed.

19. Evaluation of Carious Lesions Dental caries is diagnosed by the following: Visual changes in tooth surface Tactile sensation while using explorer Radiography—Definite radiolucency indicating a break in the continuity of enamel is carious enamel Transillumination. A translucency producing a characteristic shadow on the proximal surface indicates presence of caries.

20. Evaluation of Existing Restorations Proximal overhangs Marginal gap or ditching Amalgam blues Voids Fracture line Recurrent caries at the margin of the restoration also indicates repair or replacement of the restoration.

21. Radiograph Radiographs are useful in the following ways: Establishing diagnosis Determining the prognosis of tooth Disclosing the presence and extent of caries Determining thickness of periodontal ligament Checking presence or absence of lamina dura To look for any lesion associated with tooth To see the number, shape, length and pattern of the root canals To check any obstructions present in the pulp space To check any previous root canal treatment if done To look for presence of any intraradicular pins or posts To see the quality of previous root canal filling To see any resorption present in the tooth To check the presence of calcification in pulp space To see rootend proximal structures Help in determining the working length, length of master gutta percha cone and quality of obturation. Disadvantages • Radiograph gives two dimensional picture of a three dimensional object • Caries is always more extensive clinically when compared to radiograph

22. Study Casts Study casts help in study of the following: To educate the patient Occlusal relationship Tilted or extruded teeth Cross bite Plunger cusps Wear facet.

23. Occlusion Examination Through occlusal examination, one can identify the signs of occlusal trauma such as enamel cracks, tooth mobility and other occlusal abnormalities. During occlusal examination one should check presence of supraerupted teeth, spacing, fractured teeth and marginal ridge discrepancies. Teeth are examined for abnormal wear patterns, such as nocturnal bruxism or para-functional habits in addition to unfavorable occlusal relationships such as plunger cusp, which may result in food impaction.

24. Pulp Vitality Tests Various types of pulp tests performed are: Thermal test Cold test Heat test Electrical pulp testing Test cavity Anesthesia testing Bite test.

25. Thermal Test Cold test: Commonly used methods for performing cold pulp test are following: Spraying cold air directed against the isolated tooth Application of cotton pellet saturated with ethyl chloride Spray of ethyl chloride after isolating tooth with rubber dam (Ethyl chloride evaporates so rapidly that it absorbs heat and thus, cools the tooth). Application of dry ice on the facial surface of the tooth after isolating the oral soft tissues and teeth with gauze or cotton roll. The frozen carbon dioxide (dry ice) is available in the form of solid sticks having extremely low temperature. It should not come in contact with oral tissues because soft tissue burns may occur. Wrap an ice piece in the wet gauze and apply to the tooth. The ice sticks can also be prepared by filling the discarded anesthetic carpules with water and placing them in refrigerator.

26. Heat test: Heat test is most advantageous in the condition where patient’s chief complaint is intense dental pain upon contact with any hot object or liquid. It can be performed using different techniques. • The easiest method is to direct the warm air to the exposed surface of tooth and note the patient response. • If higher temperature is needed to elicit a response, then other options like heated stopping stick, hot burnisher, hot water, etc. can be used. Among these, heated gutta percha stick (Fig. 8.25) is most commonly used method for heat testing. In this method, tooth is coated with a lubricant such as petroleum jelly to prevent the gutta percha from adhering to tooth surface. The heated gutta percha is applied at the junction of cervical and middle third of facial surface of tooth and patient’s response is noted. • Other methods of heat testing is use of the frictional heat produced by rotating polishing rubber disk against the tooth surface. • One more method of heat test is to deliver warm water from a syringe onto the isolated tooth to determine the pulpal response. This method is especially useful for teeth with porcelain or full-coverage restoration.

27. The preferred temperature for heat test is 150°F (65.5°C) Patient may respond to heat or cold test in the following possible ways: • Mild, transitory response to stimulus shows normal pulp. • Absence of response in combination with other tests indicates pulp necrosis. • An exaggerated and lingering response indicates irreversible pulpitis.

28. Following conditions can give false negative response, i.e. the tooth shows no response but the pulp could be possibly vital: • Recently erupted teeth with immature apex—due to incompletely developed plexus of Raschkow . Hence, incapable of transmitting pain. • Recent trauma—injury to nerve supply at the apical foramen or because of inflammatory exudates around the apex may interfere the nerve conduction. • Excessive calcifications may also interfere with the nerve conduction. • Patients on premedication with analgesics or tranquilizers may not respond normally

29. Electric Pulp Testing Electric pulp tester is used for evaluation of condition of the pulp by electrical excitations of neural elements within the pulp. The pulp tester is an instrument which uses the gradations of electrical current to excite a response from the pulpal tissue. A positive response indicates the vitality of pulp. No response indicates nonvital pulp or pulpal necrosis.

30. Procedure Isolation of the teeth to be tested is one of the essential steps to avoid any type of false positive response. Apply an electrolyte on the tooth electrode and place it on the facial surface of tooth. One should note that there should be a complete circuit from electrode through the tooth to the body of the patient and then back to the electrode. If gloves are not used, the circuit gets completed when clinician’s finger contacts with electrode and patient’s cheeks. But with gloved hands circuit can be completed by placing patient’s finger on metal electrode handle or by clipping a ground attachment onto the patient’s lip. Once the circuit is complete, slowly increase the current and ask the patient to point out when the sensation occurs. Each tooth should be tested 2 to 3 times and the average reading is noted. If the vitality of a tooth is in question, the pulp tester should be used on the adjacent teeth and the contralateral tooth, as control.

31. Disadvantages Following conditions can give rise to wrong results: In teeth with acute alveolar abscess. Electrode may contact gingival tissue thus giving the false positive response. In multirooted teeth, pulp may be vital in one or more root canals and necrosed in others, thus eliciting a false positive response. • In the following conditions, false negative response is seen: – Recently traumatized tooth – Recently erupted teeth with immature apex – Patients with high pain threshold – Calcified canals – Poor battery or electrical deficiency in plug of pulp testers – Teeth with extensive restorations or pulp protecting bases under restorations – Patient’s premedicated with analgesics or tranquilizers, etc

32. Test Cavity This method should be used only when all other test methods are inconclusive in results. Here, a test cavity is made with high speed number 1 or 2 round burs with appropriate air and water coolant. The patient is not anesthetized while performing this test. Patient is asked to respond if any painful sensation occurs during drilling. The sensitivity or the pain felt by the patient indicates pulp vitality. Here, the procedure is terminated by restoring the prepared cavity. If no pain is felt, cavity preparation may be continued until the pulp chamber is reached and later on endodontic therapy may be carried out.

33. Anesthesia Testing When patient is not able to specify the site of pain and when other pulp testing techniques are inconclusive, the selective anesthesia may be used. The main objective of this test is to anesthetize a single tooth at a time until the pain is eliminated. It should be accomplished by using intraligamentary injection. Injection is administered to the most posterior tooth in the suspected quadrant. If the pain persists, even after tooth has been fully anesthetized, repeat the procedure to the next tooth mesial to it. It is continued until the pain disappears. If source of pain cannot be determined, repeat the same technique on the opposite arch

34. Bite Test This test helps if patient complains of pain on mastication. Tooth is sensitive to biting if pulpal necrosis has extended to the periodontal ligament space or if a crack is present in a tooth. In this, patient is asked to bite on a hard object such as cotton swab, tooth pick or orange wood stick with suspected tooth and the contralateral tooth. Tooth slooth is another commercially available device for bite test. It has a small concave area on its top which is placed in contact with the cusp to be tested. Patient is asked to bite on it. Pain on biting may indicate a fractured tooth.

35. Laser Doppler Flowmetry (LDF) Laser Doppler flowmeter was developed by Tenland in 1982 and later by Holloway in 1983. The technique depends on Doppler principle in which a low power light from a monochromatic laser beam of known wavelength along a fiberoptic cable is directed to the tooth surface, where the light passes along the direction of enamel prisms and dentinal tubules to the pulp. The light that contacts a moving object is Doppler shifted, and a portion of that light will be back scattered out of tooth into a photodetector. Some light is reflected off moving red blood cells in pulpal capillaries and as a consequence frequency broadened. The reflected light is passed back to the flowmeter where the frequency broadened light, together with laser light scattered from static tissue, is photodetected for strength of signal and pulsatility