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diagnosis and treatment planning

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  • 1. Diagnosis and Treatment Planning
  • 2. Definition
    • Diagnosis is the determination of the nature of a diseased condition by careful investigation of its symptoms and history
  • 3. Sequence of Events
    • Medical History Review
    • Subjective History
    • Objective Testing
    • Analysis of data collected – Clinical diagnosis
    • Plan of Action
  • 4. Medical History Review
    • Review/update written medical questionnaire
    • Medications
    • Allergies
    • Need for SBE prophylaxis
    • Diabetes
    • Pregnancy
    • Written consultation with physician as required
  • 5. Medical History Review
    • SBE Prophylaxis
    • Required for endodontic treatment in at risk patients
    • AHA recommendations should be followed
  • 6. Medical History Review
    • Prescribe :
      • 2 grams Amoxicillin 1 hour prior to treatment
      • Clindamycin 600 mg for penicillin allergic patients
  • 7. 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
  • 8. Medical History Review
    • Pregnancy
    • Avoid treatment in first and third trimesters
    • Keep radiographic exposure to a minimum
  • 9. 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
  • 10. Medical History Review
    • The only systemic contraindications to endodontic therapy are:
    • Uncontrolled diabetes
    • A very recent myocardial infarct
  • 11. Subjective History
    • Chief complaint
    • In patient’s own words
      • “ My tooth hurts when I chew hard foods”
      • “ I can’t drink cold soda”
  • 12. Pain History
  • 13. Subjective History
    • Pain History
      • Location
      • Intensity
      • Duration
      • Stimulus
      • Relief
      • Spontaneity
  • 14. Pulpal Pain
    • Very poorly localized
      • Intermittent
      • Throbbing
      • Intensified by heat, cold and sometimes chewing
      • May be relieved by cold
      • Usually severe
  • 15. Pulpal Pain
  • 16. Periradicular Pain
    • May be well localized
    • Deep pain
    • Intensified by chewing
    • Moderate to severe in intensity
  • 17. Periodontal Pain
    • May be well localized
    • Intensified by chewing
    • Moderate to severe in intensity
  • 18. Periradicular /Periodontal Pain
  • 19. Subjective History
    • Gives rise to tentative diagnosis
    • Determines urgency of treatment
    • Confirmed by examination and special tests
  • 20. Objective Testing
    • Visual Examination
    • Radiographs
    • Percussion
    • Palpation
    • Mobility
    • Thermal tests
  • 21. Objective Testing
    • Electric Pulp Test
    • Periodontal probing
    • Selective anesthesia
    • Test cavity
    • Transillumination
    • Occlusion
  • 22. Visual Examination
    • Extra-oral examination
      • Facial asymmetry
      • Swelling
      • Extra oral sinus tract
      • TMJ
  • 23. Extra-oral Swelling
  • 24. Visual Examination Extra oral sinus tracts associated with necrotic teeth
  • 25. Visual Examination
    • Intra-oral examination
    • Soft tissue lesions
        • Swelling
        • Redness
        • Sinus tract
  • 26. Acute apical abscess Acute apical abscess Incision and drainage
  • 27. Visual Examination A sinus tract should be traced with a gutta-percha cone
  • 28. Visual Examination
    • Hard tissues
    • Caries
    • Large or defective restorations
    • Discolored/chipped teeth
  • 29. Discoloration
  • 30. Radiographs
    • Always take your own pre-operative radiograph
    • Never make a diagnosis based on radiographic evidence alone
  • 31. Radiographs
    • Consider taking a bitewing film of posterior teeth
    • Note characteristic appearance of fractured root
  • 32. Radiographs Characteristic J-shaped or halo lesion associated with fractured root
  • 33. 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
  • 34. Percussion Test Vertical percussion Horizontal percussion
  • 35. Percussion Test Tooth Slooth Used to assess cracked teeth and incomplete cuspal fractures
  • 36. 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
  • 37. Palpation
  • 38. 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
  • 39. 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
  • 40. Thermal Tests
  • 41. Thermal Tests Ice stick CO2 Snow
  • 42. 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
  • 43. 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)
  • 44. 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
  • 45. 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
  • 46. Electric Pulp Test
  • 47. 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
  • 48. Electric Pulp Testing
  • 49. 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
  • 50. Periodontal Examination
  • 51. Periodontal Examination An isolated deep pocket may indicate a root fracture
  • 52. 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
  • 53. Test Cavity
    • Initiation of cavity preparation without anesthesia
    • Test of last resort
  • 54. Transillumination
    • Helps to identify vertical crown fracture
    • Produces light and dark shadows at fracture site
  • 55. Transillumination A crack will block and reflect the light when transilluminated
  • 56. Occlusion
    • Hyperocclusion – a possible cause of percussion sensitivity
  • 57. Analysis
    • Analyze the data gathered via:
      • History
      • Examination
      • Special tests
    • Arrive at a clinical (not histologic) diagnosis:
      • Pulpal diagnosis
      • Periapical diagnosis
  • 58. Possible Pulpal Diagnoses
    • Normal
    • Reversible pulpitis
    • Irreversible pulpitis
    • Necrosis
    • Previous endodontic treatment
  • 59. Normal Pulp
    • Symptoms None
    • Radiograph No periapical change
    • Pulp tests Responds normally
    • Periapical tests Not tender to percussion or
    • palpation
  • 60. 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
  • 61. 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
  • 62. Necrotic Pulp
    • Symptoms No thermal sensitivity
    • Radiograph Dependent on periapical status
    • Pulp tests No response
    • Periapical tests Dependent on periapical status
  • 63. Possible Periapical Diagnoses
    • Normal
    • Acute apical periodontitis
    • Chronic apical periodontitis
    • Chronic apical periodontitis with symptoms
    • Acute apical abscess
    • Chronic apical abscess
    • Condensing osteitis
  • 64. Normal Periapex
    • Symptoms None
    • Radiograph No periapical change
    • Pulp tests Responds normally
    • Periapical tests Not tender to percussion or palpation
  • 65. 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
  • 66. Chronic Apical Periodontitis
    • Symptoms None
    • Radiograph Periapical radiolucency
    • Pulp tests No response
    • Periapical tests Not tender to percussion or palpation
  • 67. Chronic Apical Periodontitis with symptoms
    • Symptoms Pain on pressure
    • Radiograph Periapical radiolucency
    • Pulp tests No response
    • Periapical tests Tender to percussion and/or palpation
  • 68. Acute Apical Abscess
    • Symptoms Swelling and severe pain
    • Radiograph +/- periapical radiolucency
    • Pulp tests No response
    • Periapical tests Tender to percussion and palpation
  • 69. Chronic apical abscess
    • Symptoms Draining sinus – usually no pain
    • Radiograph Periapical radiolucency
    • Pulp tests No response
    • Periapical tests Not tender to percussion or palpation
  • 70. Condensing Osteitis
    • Symptoms Variable
    • Radiograph Increased bone density
    • Pulp tests Dependent on pulp status
    • Periapical tests +/- tenderness to percussion and palpation
  • 71. Treatment Planning
    • Treatment decisions are based on:
      • Pulpal diagnosis
      • Periapical diagnosis
      • Restorability of tooth
      • Periodontal considerations
      • Difficulty of case
      • Financial considerations
  • 72. Treatment Planning
    • Two major decisions:
    • Is root canal therapy indicated?
    • Should I carry out this treatment myself or should I refer the case?
  • 73. Factors that add risk to Endodontic Cases
    • Patient considerations
    • Objective clinical findings
    • Additional conditions
  • 74. Patient Considerations
    • Medical history
    • Local anesthetic considerations
    • Personal factors and general considerations
  • 75. Objective Clinical Findings
    • Diagnosis
    • Radiographic findings
    • Pulpal space
    • Root morphology
    • Apical morphology
    • Malpositioned teeth
  • 76. Additional Conditions
    • Restorability
    • Existing restoration
    • Fractured tooth
    • Resorptions
    • Endo-perio lesions
    • Trauma
    • Previous endodontic treatment
    • Perforations
  • 77. 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
  • 78. AAE Case Difficulty Assessment Form
  • 79. 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
  • 80. Presenting complaint
    • “ I had a crown placed about 6 years ago and now but I have a blister over that tooth”
  • 81. 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
  • 82. Medical History
    • Allergy to penicillin
    • Aspirin upsets pt’s stomach
  • 83. Subjective history
    • No subjective symptoms
    • Pt reports presence of ‘blister’ on gum
  • 84. Examination
    • Extra-oral examination
      • No facial asymmetry
      • No cervical lymphadenopathy
      • No muscle or joint tenderness
    • Intra-oral examination
      • Sinus present buccal to #14
  • 85. 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
  • 86. Special tests 49 Not possible to test No response 56 EPT Normal Normal No response Normal Thermal Negative Negative Negative Negative Percussion 3 15 14 13 Tooth #
  • 87. Pre-operative film
  • 88. Diagnosis
    • Pulpal necrosis
    • Chronic apical abscess
    • RCT and restoration
    • Medical history does not affect treatment plan
  • 89. Access and Working length
  • 90. Completed RCT
  • 91. Summary
    • Pulpal Diagnoses
    • Normal
    • Reversible pulpitis
    • Irreversible pulpitis
    • Necrosis
  • 92. Summary
    • Periapical Diagnoses
    • Normal
    • Acute periradicular periodontitis
    • Chronic periradicular periodontitis
    • Acute apical abscess
    • Chronic apical abscess
    • Condensing osteitis
  • 93. 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
  • 94. Summary
    • Treatment Planning
    • Root canal therapy is indicated in situations in which the pulp cannot recover:
      • Irreversible pulpitis
      • Pulpal necrosis
  • 95. 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

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