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Diagnosis in endodontics /certified fixed orthodontic courses by Indian dental academy


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Welcome to Indian Dental Academy …

Welcome to Indian Dental Academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy has a unique training program & curriculum that provides students with exceptional clinical skills and enabling them to return to their office with high level confidence and start treating patients

State of the art comprehensive training-Faculty of world wide repute &Very affordable.

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  • 1. DIAGNOSIS INENDODONTICS INDIAN DENTAL ACADEMY Leader in Continuing Dental Education
  • 2. INTRODUCTION Diagnosis is the process of identifying adisease by careful investigation of itssymptoms and history. An accurate diagnosis is the result ofsynthesis of scientific knowledge, clinicalexperience, intuition and common sense. Theprocess is thus both an art and science.
  • 4. The four components of diagnostic procedure are1.Assemble all available facts Chief complaint Medical & Dental history Subjective symptoms History of the present condition2. Screen & interpret the assembled clues and discover which are genuine to the case3. Differential Diagnosis4. Operational or working diagnosis which is the final diagnosis
  • 5. PATIENT QUESTIONNAREFirst Name:______________ Last Name:_______________1. Are you experiencing any pain at this time? Yes ___ No ___2. If yes, can you locate the pain? Yes ___ No ___3. When did you first notice the symptoms? ________________________4. Did symptoms occur suddenly or gradually? _____________________5. Do you grind or clench your teeth? Yes ___ No ___6. If so, do you wear a night guard? Yes ___ No ___7. Has a restoration (filling 0r crown) been placed on this tooth recently? Yes ___ No ___8. Prior to this appointment, has root canal therapy been started on this tooth? Yes ___ No ___9. Any past trauma or injury to this tooth? Yes ___ No ___10. If yes, describe past trauma and state the occurrence date. __________________________________________________________11. Is there anything else about your teeth, gums or sinuses. __________________________________________________________Please check the frequency, quality and intensity of your painLEVEL OF INTENSITY FREQUENCY QUALITY1__ 2__ 3__ 4__ 5__ 6__ 7__ 8__ 9__ 10__ Constant__ Sharp__ Intermittent__ Dull__ Momentary__ Throbbing__ Occasional__
  • 6. SUBJECTI VE I NFORMATI ON OBJECTI VE I NFORMATI ON History of pain Visual examination Stimulus of pain Percussion and palpation Frequency of pain Caries and fractured Severity of pain restorations Duration of pain Sinus tracts Spontaneity of pain Tooth fractures Location of pain Extensive restoration Character of pain Exposed dentin, wear facets Alleviation of pain Periodontal disease, mobilityRADI OGRAPHI C ASSESSMENT COMPARATI VE TESTI NG Tooth length, no. of roots Thermal tests Calcifications, orifice location Electric pulp tests Number of canals, radiolucencies Anesthetic test, test cavity Resorptions, fractures Transillumination ASSESSMENT OF PULP AND PERI RADI CULAR TI SSUES PLAN OF TREATMENT
  • 7. CHIEF COMPLAINT“Listen to your patient. He is trying to tell you whatis wrong with him”. (Sir William Osler) Chief complaint is the history of the symptomsnoted in the patient’s own words that describes thesymptoms causing the discomfort.
  • 8. A proper diagnosis begins with informationabout the patient’s chief complaint, along with theobjective findings found through clinical andradiographic examinations coupled withappropriate pulp tests. Compare the patient’s signs and symptoms andtest results to known disease entities in thedifferential diagnosis and select the closest match,which becomes the operational or workingdiagnosis.
  • 9.  An astute clinician always remains open to further input that could modify the diagnosis and potentially the treatment as the unfolding of the information progresses. The importance of accurate diagnosis cannot be over emphasized.
  • 10. PAIN The alleviation of dental pain is one ofthe prime objective of the dentalprofession. Management of pain is to establishdiagnosis and treat the conditionefficiently and effectively.
  • 11. Often diagnostic decisions concerning the pulpalstatus is based on symptoms alone e.g. ” anirreversible disease state - immediate treatment ora reversible disease state - palliative treatment orobservation “.
  • 12. Wait & Watch approach is adopted in the followingconditions1. Short term sensitivity or discomfort2. History of recent dental treatment or loss of restoration or possible fractured cusp.
  • 13. Definitive pulpal treatment is indicated when the following conditions are present1. History of moderate or severe pain with recurring episodes of spontaneous pain over long period of time.2. Painful symptoms produced by specific stimuli such as biting /taking hot or cold food.
  • 14. CLINICAL EXAMINATIONVISUAL EXAMINATION:Extra oral examinationIntra oral examinationSoft tissues: Color Contour Consistency Sinus opening
  • 15. VISUAL INSPECTIONCOLOUR Normal crown- life like translucency Discolored opaque – inflamed, degenerated or necrotic pulp. Calcified Canal – Light Yellow Hue of the Crown Pink Tooth – Indicates Internal ResorptionCROWN CONTOUR Wear Facets, Fractures and RestorationsCaries Examination Diagnodent – is useful for early caries diagnosis.
  • 16. PALPATIONDigital pressure is used to check for tenderness in the oral tissues overlying the suspected teeth.Bimanual palpation is most efficient to detect incipient swellings before it is clinically evident.
  • 17. PERCUSSIONNormal resonant sound on percussion indicates good periodontal ligamentDull sound on percussion indicates ankylosis.Response to percussion not only indicates the involvement of the PDL but also the extent of the inflammation.(degree of response directly proportional to degree of inflammation). Chronic periapical inflammation is often negative to Percussion.
  • 18. Inflammation of the PDL may be caused by occlusion, trauma, sinusitis, periodontal disease or extension of pulpal disease .Percussion is not a test of pulp vitality.
  • 19. PERIODONTAL CONSIDERATIONSPeriodontal probing should be 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.
  • 20. MOBILITYTooth mobility provides an indication of the integrity of the attachment apparatus.Causes may be recent trauma, crown/root fracture, chronic bruxism, habits and orthodontic tooth movement.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.
  • 21.  As we move forward in this new millennium the science of endodontology (endodontics) has reached its leaps and bounds. The pathway to the most probable diagnosis was enhanced significantly with the popularization of electric pulp testing and availability of information from the dental radiographs. “OTTO WALKOFF who took the first dental radiograph and EDMUND KELLS used it for diagnosis during root canal treatment deserve a mention for their pioneering work in our field”.
  • 22. RADIOGRAPHS Radiographs are an important and necessary adjunct in Endodontics. Periapical and Bite wing radiographs are mainly used. Accurate radiographic techniques and proper interpretation are essential for sound diagnosis and treatment. Radiographs are used for determining pulpal anatomy prior to access openings. Establishing working length. Confirm master cone placement and for evaluating the success of treatment.
  • 23. Bite wing radiographs are helpful to Detect recurrent decay Detect the depth of pulp chamber. Peri radicular pathosis / bone destruction is not evident in the radiograph, until there is significant erosion of the cortical plate because bone loss is confined to the cancellous bone. With a mineral content of 52% of the cortical bone, there must be a 6.6% loss of bone mineral in order for the lesion to become radiographically visible.
  • 24. Features seen in high quality periapical radiographs (ortho radial projection) include caries Sharp outline of the root Tooth length Number of roots and canals Calcification Hard tissue deposits Internal/External resorption Periapical lesions Perforations Fractures
  • 25. CARIES Caries progression is divided into five radiographic gradesGrade 1 – Caries in enamelGrade 2 – Reaches the DE junctionGrade 3 – Radiolucency extends halfway into dentin thicknessGrade 4 – Deeper dentinGrade 5 – involving the pulp
  • 26. Caries Examination Receding pulp horn – age changes, chronic carious lesion In Posterior teeth,  Mesial Carious Lesion – more commonly involves pulp,  Distal Carious Lesion – Silent Killer – takes a longer time. Deep caries involvement of mesial Pulp horn causes minimal periapical changes either in mesial/distal root.
  • 27. The morphological features to be noted regarding root canal anatomy Length – longer or shorter Shape – Blunder buss Taurodontism Dens in Dente Root with bulbous ends Curved canals – Degree of curvature X-ray exposed at 15º horizontal angle can help visualize curvature in bucco-lingual plane.
  • 28.  Number of canals Always look and expect for extra canals (Mandibular Incisor & Premolar, Maxillary First Molar) When large canals stop abruptly, look for branching ResorptionInternal resorption – Continuous with canalExternal resorption – Super imposed. Calcification Can be either isolated or continuous
  • 29. FRACTURES Vertical Root Fractures - Cannot be seen through radiographs - Look for haziness surrounding the roots Transillumination Fiber optic wand, otoscope with fiber optic attachment or fiber optic hand piece may be used. Composite curing lights are not recommended as they may illuminate the entire crown and not highlight the fracture line as with fiber optics. Tooth slooth Horizontal and oblique fractures - Two x-rays are needed to locate these fractures
  • 30. Things to look for in radiographs Cervical burnout : It is a diffuse radiolucent area on the proximal side. Decreased x-ray absorption in that area should not to be confused with root caries. Lamina dura: Parallel – well defined Oblique – diffuse Thickened/dense – Heavy occlusal forces Intact lamina dura – Vital pulp
  • 31.  Alveolar Crest: - Normal 1.5 mm from the C-E junction - Crest of bone is continuous with the lamina dura and forms a sharp angle with junctional epithelium - Rounding of this sharp junction indicates periodontal disease. Periodontal ligament space - Space is thinner in middle of the root and widened near alveolar crest and root apex.
  • 33. ANTERIOR NASAL SPINE Seen in the midline
  • 34. NASAL FOSSASeen in the midline above the anterior nasal spine.
  • 35. INCISIVE FORAMEN Symmetrical Variable position May be present at the apex of the central incisor roots and even up to the alveolar crest.
  • 36. SUPERIOR FORAMINA OF NASOPALATINE CANAL  Occasionally appear when exaggerated vertical angle is used.
  • 37. MAXILLARY SINUS Close proximity of root apices to maxillary sinus.
  • 38. MANDIBLE SYMPHISIS – GENIAL TUBERCLE – Seen in occlusal radiograph. MENTAL FOSSA – Present in the labial aspect of mandible. MENTAL FORAMEN - Seen half way between lower border of mandible and crest of alveolar process, usually in the region of apex of second premolar and its position is influenced by angulation.
  • 39. MANDIBULAR CANAL Continuous with the apex of third molar Distance from root increases as it progresses anteriorly Appears as tram lines in the radiograph.
  • 40. LIMITATIONS OF RADIOGRAPHS Radiograph is a two dimensionalrepresentation of a three dimensional object.Hence magnifying loupes are recommendedfor more exact interpretation. Radiographic misdiagnosis – if there is onlybuccal/ cervical involvement (deep caries) Besides diagnostic radiograph, additionalradiographs are necessary depending onspecific situations.
  • 41. 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.
  • 42. Vertical shift of tube enables to visualize the rootapices which are superimposed by the zygomatic arch.Other films like Panograms Lateral jaw projections Occlusal radiographs are also useful in determining the three dimensional extent of a lesion.
  • 43. Another limitation of radiographs is interpretation.“All meanings, we know, depend on the key of interpretation” - EAST
  • 44. Radiolucency at Furcation Area  May be due to,  Periodontal Involvement,  Accessory Canals,  Cervical Pulp Horn.
  • 45. Points to be checked during radiographic interpretations include Clear films / Additional films Is root canal system within normal limits (Calcifying or resorbing)? Is lamina dura intact or not? Is bony architecture within normal limits? What anatomical landmark can be expected in this area?
  • 46. Digital Radiography (RVG) Reduced radiation exposure – 80% less Immediate availability of image No need of processing materials Ability to store data Relief image or contrast image
  • 47. PULP VITALITY TESTS Assessment of vitality using routine methods rely on the stimulation of Aδ nerve fibers and there is no direct indication of the blood flow. Three methods are used to stimulate the Aδ nerve fibers1. Thermal stimulation2. Electrical stimulation3. Direct dentin stimulation.
  • 48. THERMAL STIMULATION Inexpensive The temperature used is 65.5ºC to elicit the response Can use Gutta percha – (base plate gutta percha) Cast metal crown restorations are too thick to allow heated GP to elicit response In such cases a rubber wheel is used to elicit the response
  • 49. COLD TEST Various materials used for cold test are – Cones of ice - -20ºC – Ethyl chloride spray - - 40ºC – Carbon- di- oxide snow – -70ºC Application of cold for 4 seconds lowers the temperature to between 26 and 30ºC eliciting pain. Within the pulp temperature is lowered by 0.2ºC.
  • 50. Heat causes vasodilatation and increase in intrapulpal pressure (releases gaseous product ofproteolysis) (VAN HASSEL).In an intact pulp specific pulpal temperaturemust be reached before there is pain from heat. Therefore, application of heat to normal teethgives delayed response.In a tooth with inflamed pulp, increased intrapulpal pressure already exists. Thereforeimmediate painful response to gradual/suddenincrease in heat.
  • 51. COLDCold decreases intrapulpal pressure in normal intact pulp and there is no pain.The pain from cold is due to hydrodynamic mechanism.Contraction of fluid causes outward flow of fluid in dentinal tubules, deforms Aδ nerve and an action potential is generated.In advanced acute pulpitis, no Aδ receptors are present. Cold produces contraction and lowers the intrapulpal pressure to a sub threshold level and relieves pain due to still viable C fibers.Pain returns within 30 – 60 seconds as intra pulpal pressure returns to its former suprathreshold level.
  • 52. ELECTRIC PULP TEST Electrolyte applied on the teeth to transmit current Jelly used for ECG is ideal When electrolyte contacts the tooth an electric charge is applied by pressing rheostat button. A small charge is released initially and increased until response is felt. Select control teeth – contra lateral teeth and adjacent teeth.
  • 53. INTERPRETATION If the current required to gain a response from a test tooth is same as that needed to excite the control – the pulp of the test tooth is considered normal. If less current is required for a response – Hyperactive If more current is required– delayed response/ high pain threshold Lack of response – Pulpal necrosis
  • 54.  Two readings are recorded and the average value is taken. “Using EPT on any tooth more than 4 times can give wrong reading due to additive action.”
  • 55.  Only Aδ fibers are activated by electric tests Aδ fibers produce initial momentary sharp response to electric stimuli because of its peripheral location, low threshold & greater conduction velocity. Continuous constant pain is produced by the smaller C fiber stimulation as it is associated with tissue damage and inflammatory process.
  • 56. DISADVANTAGES Battery plug in Electrical deficiencies Output current variations Battery run down and not delivering full current all these give variable results with EPT Molars give readings not indicative of the true pulpal condition.
  • 57. LIMITATIONS Tests are not reliable on immature teeth of young patients as these teeth contain fewer Aδ fibers than mature teeth and myelinated nerves do not reach their maximal depth of penetration into the pulp until the apex completes its development.
  • 58.  When comparing teeth in question with the control teeth, pulps of the control teeth may not be normal. Teeth with acute alveolar abscess may respond positively to EPT because the gaseous and liquefied elements within the pulp can transmit electric charges to periapical tissues.
  • 59.  In traumatic injuries, in the cervical areas there will be temporary paraesthesia of the nerves. If pulp vitality remains, the pulp will respond within normal limits after 30 to 60 days.
  • 60. Current methods of stimulation of Aδfibers give no direct indication of the bloodflow within the pulp. These methods are all subjective tests thatdepend on patients response to stimulus aswell as dentist’s interpretation. Assessment of the blood flow is the idealtest for vitality.
  • 61. Research is the primary catalyst toprofessional growth and has greatly added to the understanding of the etiology,diagnosis and treatment of dental diseases.
  • 62. PULSE OXIMETRY It is a non invasive oxygen saturation device for recording blood oxygen saturation levels. Based on BEER’s law – Absorption of light by a solute to its concentration and its optical properties at a given wave length. The system consists of probe with diode that emits light in two wavelengths. – Red light of approximately 600 nm – Infra red light of approximately 850 nm Detects presence or absence of oxygen in blood at 760nm/860nm.
  • 63. LASER DOPPLER FLOWMETRY Based on the principle that reflected light fromblood flow will demonstrate a Doppler effect,depending on the relative velocity of the blood flow& probe. There are two typesa) Direct laser Doppler flowmetry.b) Indirect laser flowmetry.
  • 64. SPECIAL TESTSThe apt test for teeth restored with composite eliciting features of pulpitis is the cold test.In teeth with full crown coverage hot water/ coffee test .Wedging and staining – methylene blue, erythrosine dye.Selective anesthesia test Intra ligamentry anesthesia into the distal sulcus provides relief of pain in the affected tooth.
  • 65. Test Cavity- The Confirmatory Test Teeth that exhibit mixed response to pulp testing - confirmed with Test Cavity. Teeth with ceramic crown – test cavity is done on the Palatal aspect for anteriors & Occlusal for posteriors.
  • 66. Difference between pulp and periodontal disease Pulpal PeriodontalCause Pulp infection Periodontal infectionVitality Non vital vitalRestorative Deep or Not related extensivePlaque/calculus Not related Primary causeInflammation Acute chronicTrauma Primary or Contributing secondary factor
  • 67. DIFFERENTIAL DIAGNOSISThe step in diagnosis to distinguish onedisease from several other similar diseasesby identifying their differences.
  • 68. CLI NI CAL CHARACTERI STI CS OF REVERSI BLE PULPI TI S• Sensitivity to mild discomfort• Short duration or shooting sensation• Not severe• Infrequent episodes of discomfort• Common causes include exposed dentin, cracked restorations, recently placed restorations, initial carious attack or rapidly advancing caries, altered occlusion• Could result in irreversible pulpitis if cause not removed• Symptoms usually subside immediately or shortly after removal of the cause
  • 69. CLI NI CAL CHARACTERI STI CS OF I RREVERSI BLE PULPI TI S• Pain may be absent or present• If present, pain is moderate to severe• Pain is often spontaneous, increasing in frequency, often to a point of being continuous• Pain usually lingers, especially with increasing episodes• Thermal stimulation often elicits severe lingering pain• Pain radiates or is diffuse or may be localized• History of trauma, extensive restorations, periodontal disease or extensive recurrent caries is present.
  • 70. CLINICAL CHARACTERISTICS OF SUB - ACUTE PERIRADICULAR PERIODONTITIS Slight tenderness to biting or percussion No lesion present on radiographs
  • 71. CLI NI CAL CHARACTERI STI CS OF ACUTE PERI RADI CULAR PERI ODONTI TI S• Pain to biting or percussion• No thickened ligament space or lesion present• Tooth may be mobile• Often tender to palpation
  • 72. CLI NI CAL CHARACTERI STI CS OF CHRONI C PERI RADI CULAR PERI ODONTI TI S• Patient asymptomatic• If sinus tract present, referred to as suppurative• Percussion produces little or no discomfort
  • 73. CLI NI CAL CHARACTERI STI CS OF ACUTE ALVEOLAR ABSCESS• Severe pain with biting, percussion and palpation• Tooth elevated in the socket• Tooth very mobile• Swelling may be present• Often systemic symptoms present
  • 74. CONCLUSION With proper integration of clinical and radiographic factors, in an environment that minimizes the shackles of bias, the wise and prudent clinician will be able to assess both the process and completed treatment.