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By: aashwiin7375 (12 month(s) ago)

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Diagnosis and Treatment Planning : 

Diagnosis and Treatment Planning

Definition: 

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

Sequence of Events: 

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

Medical History Review: 

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

Medical History Review: 

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

Medical History Review: 

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

Medical History Review: 

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

Medical History Review: 

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

Medical History Review: 

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

Medical History Review: 

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

Subjective History: 

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

Pain History: 

Pain History

Subjective History: 

Subjective History Pain History Location Intensity Duration Stimulus Relief Spontaneity

Pulpal Pain: 

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

Pulpal Pain: 

Pulpal Pain

Periradicular Pain: 

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

Periodontal Pain: 

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

Periradicular /Periodontal Pain: 

Periradicular /Periodontal Pain

Subjective History: 

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

Objective Testing: 

Objective Testing Visual Examination Radiographs Percussion Palpation Mobility Thermal tests

Objective Testing: 

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

Visual Examination: 

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

Extra-oral Swelling: 

Extra-oral Swelling

Visual Examination: 

Visual Examination Extra oral sinus tracts associated with necrotic teeth

Visual Examination: 

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

Acute apical abscess: 

Acute apical abscess Acute apical abscess Incision and drainage

Visual Examination: 

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

Visual Examination: 

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

Discoloration: 

Discoloration

Radiographs: 

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

Radiographs: 

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

Radiographs: 

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

Percussion Test: 

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

Percussion Test: 

Percussion Test Vertical percussion Horizontal percussion

Percussion Test: 

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

Palpation Test: 

Palpation Test Extraoral To detect swollen or tender lymph nodes Intraoral May detect early periapical tenderness Identifies soft tissue swelling Must compare with other areas

Palpation: 

Palpation

Mobility: 

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

Thermal Tests: 

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

Thermal Tests: 

Thermal Tests

Thermal Tests: 

Thermal Tests Ice stick CO2 Snow

Thermal Tests: 

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

Thermal Tests: 

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)

Electric Pulp Test: 

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

Electric Pulp Test: 

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

Electric Pulp Test: 

Electric Pulp Test

Electric Pulp Test: 

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

Electric Pulp Testing: 

Electric Pulp Testing

Periodontal Examination: 

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

Periodontal Examination: 

Periodontal Examination

Periodontal Examination: 

Periodontal Examination An isolated deep pocket may indicate a root fracture

Selective Anesthesia: 

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

Test Cavity: 

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

Transillumination: 

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

Transillumination: 

Transillumination A crack will block and reflect the light when transilluminated

Occlusion: 

Occlusion Hyperocclusion – a possible cause of percussion sensitivity

Analysis: 

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

Possible Pulpal Diagnoses: 

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

Normal Pulp: 

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

Reversible Pulpitis: 

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

Irreversible Pulpitis: 

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

Necrotic Pulp: 

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

Possible Periapical Diagnoses: 

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

Normal Periapex: 

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

Acute Apical Periodontitis: 

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

Chronic Apical Periodontitis: 

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

Chronic Apical Periodontitis with symptoms: 

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

Acute Apical Abscess: 

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

Chronic apical abscess: 

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

Condensing Osteitis: 

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

Treatment Planning: 

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

Treatment Planning: 

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

Factors that add risk to Endodontic Cases: 

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

Patient Considerations: 

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

Objective Clinical Findings: 

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

Additional Conditions: 

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

AAE Case Difficulty Assessment Form: 

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

AAE Case Difficulty Assessment Form: 

AAE Case Difficulty Assessment Form

AAE Case Difficulty Assessment Form: 

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

Presenting complaint : 

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

Dental History/History of presenting complaint: 

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

Medical History: 

Medical History Allergy to penicillin Aspirin upsets pt’s stomach

Subjective history: 

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

Examination: 

Examination Extra-oral examination No facial asymmetry No cervical lymphadenopathy No muscle or joint tenderness Intra-oral examination Sinus present buccal to #14

Special tests: 

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

Special tests: 

Special tests

Pre-operative film: 

Pre-operative film

Diagnosis: 

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

Access and Working length: 

Access and Working length

Completed RCT: 

Completed RCT

Summary : 

Summary Pulpal Diagnoses Normal Reversible pulpitis Irreversible pulpitis Necrosis

Summary: 

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

Summary: 

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

Summary: 

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

Summary: 

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