Clinical endodontic diagnosis 2009


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Clinical endodontic diagnosis 2009

  1. 1. 1 Diagnosis Pulp Pathosis Process of making a diagnosis 5 stages 1. Patient says why they have presented 2. Clinician probes with ??? – history of problem – symptoms related to current condition 3. Clinician performs OBJECTIVE tests 4. Correlation of Objective and Subjective data 5. Definitive diagnosis Adopt a systematic approach Carefully engineered ???? Elicit critical and pertinent data Listen carefully – picture will emerge to give inkling of the cause of the patients present complaint To put it simply! Question Listen Test Interpret Answer A proper approach to information gathering Differential diagnosis Provisional diagnosis Definitive diagnosis Patients reason for seeking treatment Often more important than tests performed Dentist may find pathosis Potential to cause current complaint Not the pathological condition motivating the to patient present
  2. 2. 2 Document chief complaint Make a record of the patients own words Detail the patients description of the symptoms Medical History!! Taken and reviewed with patient – patient to sign the history This will highlight the fact that this necessary step has been undertaken Review the history if patient not seen for more than 1 year Current health conditions Diseases and disorders Medications Mediate the proposed treatment Medical conditions which present oral symptoms and signs Conditions which mimic dental pathosis Examples: 1. Maxillary sinusitis Can mimic tooth ache in maxillary posterior teeth 2. Tumour of Central Nervous System, pressure on the Trigeminal Nucleus, pain in the oro-facial area 3. Myo-fascial pain Trigger points) small foci of hyper- excitable muscle tissue diffuse, dull,constant ache Mistakenly attributed to tooth or teeth 4. Trigeminal Neuralgia Intense, sharp, shooting pain, uni-lateral Trigger zone Pain subsides within few mins. Response is not proportional to the intensity of the stimulus See sample history sheets “Pathways of The Pulp” Fig. 1-1 Fig. 1-3
  3. 3. 3 Recording the results of Tests Pre-printed forms may be useful See “Pathways of The Pulp” Fig. 1-3 History of the present dental complaint Recent dental treatment What treatment Which tooth/teeth Past dental treatment History of present dental problem When started How long present Clinician’s Questioning Once the patient has given their perception of the problem This questioning should direct the interchange Questions to Ask ????????????? ????????????? Localization Put finger on or tap offending tooth Very helpful Can narrow the search Symptoms may not be well localized This presents more of a challenge Commencement When did symptoms first occur Patient may remember an initiating event E.g. recent dental treatment, trauma biting a hard object)
  4. 4. 4 Intensity Ask patients to rate pain on a scale of 1 – 10 with 10 being most severe Uncomfortable sensation to cold or an annoying pain when chewing may rate as 3 – 4 Unable to sleep with constant throbbing pain may rate a 10 Provocation What elicits the pain? Cold Hot Chewing (upon application of pressure or release) Touching (tongue, finger, toothbrush) Spontaneously Relieved by Cold Non-prescription analgesics e.g. Panadol, Nurofen, Aspirin Of particular interest are the anti- inflammatory pain medications Duration – Is it? Relieved immediately –removal of stimulus Lasting minutes or hours Intermittent – spontaneous pain that will continue for hours but remit for variable periods and commence again unstimulated Extraoral Examination 1. Visual Facial asymmetry Loss of definition of philtrum of upper lip or naso-labial fold Swelling – head, face, neck Redness 2. Palpation – Facial swelling Diffuse Firm Fluctuant Localized Lymph nodes Cervical, Sub-mandibular Uni-lateral, Bi-lateral (medical condition?)
  5. 5. 5 Facial swelling Diffuse facial swelling Localized facial swelling Examples: Uni-lateral facial swelling, firm tender lymph nodes Likely infection Localized infection has spread into surrounding tissues – now a systemic problem A diffuse facial swelling is generally of endo. origin. Rare with Perio. abscess Loss of definition of philtrum of upper lip Incisor endo. involvement Loss of definition of naso-labial fold Canine involvement Fluctuant swelling anterior palate Upper lateral incisor or first pre- molar Fluctuant swelling posterior palate Palatal roots upper molars Intra-oral Examination 1. Swelling Visualized Palpated Diffuse, localized, firm, fluctuant May be present in: Attached gingiva Alveolar mucosa Muco-buccal fold Sub-lingual Intra-oral swelling Localized intra- oral swelling, upper buccal sulcus Fluctuant swelling, anterior palate 2. Erythema 3. Sinus formation Can occur through: Attached gingiva Mucosa Furcation Perio. ligament (gingival crevice)
  6. 6. 6 Sinus Tracts Drainage of inflammatory exudate from endo. infection Exits via Stoma Stoma may be extra-oral or intra-oral Sinus tract may be lined by epithelium (not often) generally lined by granulation tissue Intra-oral sinus Attached gingiva Resolution of sinus tracts This will generally occur with appropriate and adequate endo. treatment Failure to heal Further investigation Other aetiological factors? Misdiagnosis? Examples: Swelling in the muco-buccal fold Upper molar teeth with buccal root apices inferior to the attachment of muscle in that region Lower molar teeth – buccal root apices superior to the muscle attachment Infections associated with lower molars and pre-molars Root apices above the level of mylo-hyoid Exiting to lingual Tongue elevated and swelling bi-lateral (no midline division of sub-lingual space) Post. Max. and Mand. Teeth – infection can extend into tonsilar & para-pharyngeal areas Potentially life-threatening Mandibular incisors may involve the sub-mental and sub-mandibular spaces Infection exits above mylo-hyoid attachment (sub-mental space) Infection exits inferior to mylo- hyoid (sub-mandibular space)
  7. 7. 7 Extra-oral sinus stoma Involvement of sub-mental region Other intra-oral exams 1. Palpation - Alveolar hard tissues Swelling of soft tissues overlying the bony processes Expansion of the buccal and lingual cortical plates (unlikely to be of endodontic origin) Patient sensitivity during this part of the exam 2. Percussion Patient c/o sensitivity or pain on mastication Such a sign may be elicited by percussion A measure of inflammation of the apical perio. ligament Inflammation of the Periodontal Ligament Possible causes: Physical trauma Occlusal trauma Perio disease An extension of endodontic inflammation/infection to involve the apical periodontium Proprioception Proprioceptors provide the sensory input derived from mastication, percussion and other forms of pressure on a tooth There are few, if any, in the pulp Difficult to localize pain in the early stages of pulp pathosis? Prevalent in the ligament With peri-apical ligament involvement Tooth more identifiable by percussion Diagnostic Tests
  8. 8. 8 Three primary purposes of tests 1. Reproduce symptoms 2. Localize synptoms 3. Assess severity Psycho-social issues Exaggeration/understatement When performing tests Inform the patient Reduces anxiety Enhancnes the diagnostic quality of the response Conducting tests Test a contra-lateral tooth first Test adjacent teeth next (that are more likely to give a normal response) Test the suspect tooth last Ask patient to compare the response from suspect tooth to that from normal tooth Ask if the response is painful Ask how long the pain lasts Technique for percussion Test first by tapping with gloved finger nail If no discernable result, use mirror handle very lightly Occlusally first No response then test buccally and lingually Positive response then repeat to confirm Percussion Test Mobility Degrees of mobility 1° - greater than normal 2° - less than 1mm 3° - greater than 1mm with or without vertical mobility Not a test of vitality Indicator of compromised periodontal attachment apparatus
  9. 9. 9 Mobility Test Two instrument handles Differential diagnosis – Mobility Acute physical trauma Occlusal trauma – Bruxism or other para- functional habits Advanced periodontal disease Root fracture Rapid Orthodontic movement Extension of pulp pathosis i.e. acutely infected, non-vital teeth (acute abscess) – often mobile. Endo. treatment will reverse this situation Perio examination How to differentiate perio. condition from a bony defect of endodontic origin Endo. defects Isolated, narrow opening, vertical defect. (Can be associated with a vertical crack) Endo lesions may exhibit furcation bone loss Furcation defects - perio, endo, or combined Thermal Pulp tests If patient c/o sens. to cold then test with cold Record No response Normal (WNL) Intensified (Moderate , Extreme) Lingering Cold Test Method 1,1-1,2 Tetra-fluoro Ethane Spray Largish cotton pellet (make your own) Apply to mid-facial of teeth
  10. 10. 10 Isolate and dry teeth As for percussion inform patient Test contra-lateral teeth Test adjacent teeth Test suspect tooth amongst teeth expected to give a normal response Instruct patient not to try to figure out which tooth you are testing rather to tell you “ what they feel” Offer three options 1. Cold 2. Nothing 3. Sensitivity or pain Heat Test Method Patient c/o sensitivity to hot food test with both hot and cold Isolate and dry teeth Lubricate teeth surfaces with petroleum jelley Use White gutta percha stick and heat in flame Apply to mid-facial area of teeth Adopt the same procedures as for other tests using ‘control’ teeth Heat Test Spontaneous pain A tooth that is responsive to hot is often responsible for episodes of spontaneous or continuous pain Often relieved by cold stimulus e.g. cold liquids or ice pack Pain relieved by cold
  11. 11. 11 Electric Pulp Tests Cold and electric test provide a fairly reliable indicator of vitality BUT – A molar with only one vital root will sometimes give + response to cold which may be a heightened response Electric test only gives indication of presence of any viable nerve tissue Most accurate – NO RESPONSE to any amount of current – necrotic pulp Electric pulp test unit Probe Patient completes circuit by touching metal probe handle Method Isolate, dry teeth Test contra-lateral tooth to obtain base-line level of expected response (number on the dial of the tester unit) This will familiarise patient with the sensation Test suspect tooth twice Use toothpaste as electrolyte to conduct current to tooth Apply probe to incisal 1/3 or facial aspect of post. teeth Application of the probe Tooth paste as electrolyte If little exposed tooth Crown and bridge work then look for any exposed tooth Use probe/explorer and tooth paste and touch tester probe to the explorer Cracked Tooth Patient will often complain of pain on chewing The diagnostic feature of this pain is that it is more noticeable when the pressure is released Specially designed crack testers are available – “Tooth Sleuth”
  12. 12. 12 Tooth Sleuth Place on cusp tips Pressure applied by opposing teeth Individual cusps can be tested Transillumination Prepared by Lea Foster References Pathways of the Pulp 9th Ed. Cohen, Hargreaves Endodontic Therapy 6th Ed. Weine Principles and Practice of Endodontics Walton, Torebinejad Harty’s Endodontics in Clinical Practice Pitt Ford Colour Atlas of Endodontics Willaim T Johnson