Slides - 10 - Diagnosis and Treatment Planing

7/30/2019 Slides - 10 - Diagnosis and Treatment Planing

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Dr Nawaf Al-Hazaimeh

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*Diagnosis is the science of recognizing disease by means of signs,

symptoms, and tests. Often, diagnosis is straightforward;

sometimes it is not. The basic steps in the diagnostic process are

as follows:*1. Chief complaint

*2. History: medical and dental

*3. Oral examination

*4. Data analysis

differential diagnosis*5. Treatment plan


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Diagnosis

key to start the Endo procedure


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*Medical History Review

*Subjective History

*Objective Testing

*Analysis of data collected Clinical diagnosis

*Plan of Action


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*Review/update written medical questionnaire

*Medications

*Allergies

*Need for SBE prophylaxis

*Diabetes

*Pregnancy

*Written consultation with physician as required


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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


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Latex Allergy

*Non-latex rubber dam

*Latex-free gloves

*One report of allergy to gutta-percha no definitiveproof that a true allergic reaction occurred

*Consult patients allergist


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The only systemic contraindications to endodontic therapy

are:

*Uncontrolled diabetes

*A very recent myocardial infarct


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Chief complaint

*In patients own words*My tooth hurts when I chew hard foods

*I cant drink cold soda


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Pain History

*Location

*Intensity*Duration

*Stimulus

*Relief

*Spontaneity


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Very poorly localized

*Intermittent

*Throbbing

*Intensified by heat, cold and

sometimes chewing

*May be relieved by cold

*Usually severe


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*May be well localized

*Deep pain*Intensified by chewing

*Moderate to severe in intensity


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*Gives rise to tentative diagnosis

*Determines urgency of treatment

*Confirmed by examination and special tests


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*Visual Examination

*Radiographs

*Percussion*Palpation

*Mobility

*Thermal tests


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*Electric Pulp Test

*Periodontal probing

*Selective anesthesia

*Test cavity

*Transillumination

*Occlusion


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*Extra-oral examination

*Facial asymmetry

*Swelling

*Extra oral sinus tract

*TMJ


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Extra oral sinus tracts

associated withnecrotic teeth


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A sinus tract should

be traced with a

gutta-percha cone


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Hard tissues

*Caries

*Large or defective restorations

*Discolored/chipped teeth


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*Always take your own pre-operative radiograph

*Never make a diagnosis based on radiographic evidencealone


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Characteristic J-shaped or halo lesion associated with

fractured root


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*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


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Vertical percussion Horizontal percussion


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Tooth Slooth

Used to assess cracked teeth andincomplete cuspal fractures


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*Extraoral

*To detect swollen or tender lymph nodes

*Intraoral

*May detect early periapical tenderness

* Identifies soft tissue swelling

*Must compare with other areas


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*Reflects the extent of inflammation in the PDL

*Compare with adjacent and contralateral teeth

*There are many causes of mobility besides pulpalinflammation extending into the PDL


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*Cold always used

*Heat rarely used

*Compare reaction with adjacent andcontralateral teeth

*Refractory period of at least 10 minutes

before pulp can be retested accurately

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Ice stick

CO2 Snow


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*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


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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)


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*A direct test of nerve elements of pulpaltissue

*Vitality versus non-vitality only not whethervital pulp is normal or inflamed

*In multi-rooted teeth, where one canal isvital tooth usually tests vital

*False positives and false negatives may occur


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False positive reading:

*Electrode contact with metal restoration or gingiva

*Patient anxiety

*Liquefaction necrosis

*Failure to isolate and dry teeth prior to testing


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False negative reading:*Patient is heavily premedicated

*Inadequate contact between electrode and enamel*Recently traumatized tooth

*Recently erupted tooth with open apex

*Partial necrosis


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An isolated deep pocket may indicate a root fracture

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*May help to identify thepossible source of pain

*An IDN block can localizepain to one arch

*Ability to anesthetize asingle tooth has beenquestioned


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Helps to identify vertical crown fracture Produces light

and dark shadows at fracture site.

A crack will block and reflect the light when transilluminated


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*Analyze the data gathered via:

*History

*Examination

*Special tests

*Arrive at a clinical (not histologic) diagnosis:

*Pulpal diagnosis

*Periapical diagnosis


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*Normal

*Reversible pulpitis

*Irreversible pulpitis*Necrosis

*Previous endodontic treatment


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*Symptoms None

*Radiograph No periapical change

*Pulp tests Responds normally

*Periapical tests Not tender to percussion or

palpation


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*Symptoms May have spontaneous pain


*Pulp Tests Pain that lingers

*Periapical tests Generally not tender topercussion or palpation


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*Symptoms No thermal sensitivity

*Radiograph Dependent on periapical status

*Pulp tests No response

*Periapical tests Dependent on periapical status

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*Normal

*Acute apical periodontitis

*Chronic apical periodontitis

*Chronic apical periodontitis with symptoms

*Acute apical abscess

*Chronic apical abscess

*Condensing osteitis


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*Symptoms None


*Pulp tests Responds normally

*Periapical tests Not tender to percussion or palpation

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*Symptoms Pain on pressure


*Pulp tests +/- depending on pulp status

*Periapical tests Tender to percussion and/orpalpation

High restorations, traumatic occlusion, orthodontic treatment, crackedteeth, vertical root fractures, periodontal disease and maxillary sinusitismay also produce this response


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*Symptoms None

*Radiograph Periapical radiolucency


*Periapical tests Not tender to percussion or palpation

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*Symptoms Pain on pressure

*Radiograph Periapical radiolucency


*Periapical tests Tender to percussionand/or palpation


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*Symptoms Swelling and severe pain

*Radiograph +/- periapical radiolucency


*Periapical tests Tender to percussion and

palpation

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Acute apical abscess Incision and drainage


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*Symptoms Draining sinus usually no pain

*Radiograph Periapical radiolucency*Pulp tests No response

*Periapical tests Not tender to percussion orpalpation


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Extra oral sinus tracts

associated with

necrotic teeth


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*Treatment decisions are based on:

*Pulpal diagnosis

*Periapical diagnosis

*Restorability of tooth

*Periodontal considerations

*Difficulty of case

*Financial considerations


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Two major decisions:

*Is root canal therapy indicated?

*Should I carry out this treatment myself or should Irefer the case?


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*Patient considerations

*Objective clinical findings

*Additional conditions

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*Medical history

*Local anesthetic considerations

*Personal factors and general considerations


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*Restorability

*Existing restoration

*Fractured tooth

*Resorptions*Endo-perio lesions

*Trauma

*Previous endodontic treatment

*Perforations

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Pulpal Diagnoses

*Normal

*Reversible pulpitis

*Irreversible pulpitis

*Necrosis

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*Periapical Diagnoses*Normal

*Acute periradicular periodontitis

*Chronic periradicular periodontitis

*Acute apical abscess

*Chronic apical abscess

*Condensing osteitis

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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

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Treatment Planning

*Root canal therapy is indicated in situations in which the

pulp cannot recover:

*Irreversible pulpitis

*Pulpal necrosis

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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

Slides - 10 - Diagnosis and Treatment Planing

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