diagnosis and treatment planning

38,629 views

Published on

Published in: Education
6 Comments
111 Likes
Statistics
Notes
  • This is real take it serious, who will believe that a herb can cure herpes, i navel believe that this will work i have spend a lot when getting drugs from the hospital to keep me healthy, what i was waiting for is death because i was broke, one day i hard about this great man who is well know of HIV and cancer cure, i decided to email him, unknowingly to me that this will be the end of the herpes in my body, he prepare the herb for me, and give me instruction on how to take it, at the end of the one month, he told me to go to the hospital for a check up, and i went, surprisingly after the test the doctor confirm me negative, i thought it was a joke, i went to other hospital was also negative, then i took my friend who was also herpes positive to the Dr Agumagu, after the treatment she was also confirm negative . He also have the herb to cure cancer. please i want every one with this virus to be free, that is why am dropping his email address, agumaguspelltemple@outlook.com or agumaguspelltemple@gmail.com do email him he is a great man. the government is also interested in this DR, thank you for saving my life, and I promise I will always testify for your good work.call his number +233200116937
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Hi All, We are planning to start new Salesforce Online batch on this week... If any one interested to attend the demo please register in our website... For this batch we are also provide everyday recorded sessions with Materials. For more information feel free to contact us : siva@keylabstraining.com. For Course Content and Recorded Demo Click Here : http://www.keylabstraining.com/salesforce-online-training-hyderabad-bangalore
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Hi All, We are planning to start new Salesforce Online batch on this week... If any one interested to attend the demo please register in our website... For this batch we are also provide everyday recorded sessions with Materials. For more information feel free to contact us : siva@keylabstraining.com. For Course Content and Recorded Demo Click Here : http://www.keylabstraining.com/salesforce-online-training-hyderabad-bangalore
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • pulp testing method
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Great Presentation.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total views
38,629
On SlideShare
0
From Embeds
0
Number of Embeds
45
Actions
Shares
0
Downloads
2,199
Comments
6
Likes
111
Embeds 0
No embeds

No notes for slide

diagnosis and treatment planning

  1. 1. Diagnosis and Treatment Planning
  2. 2. Definition <ul><li>Diagnosis is the determination of the nature of a diseased condition by careful investigation of its symptoms and history </li></ul>
  3. 3. Sequence of Events <ul><li>Medical History Review </li></ul><ul><li>Subjective History </li></ul><ul><li>Objective Testing </li></ul><ul><li>Analysis of data collected – Clinical diagnosis </li></ul><ul><li>Plan of Action </li></ul>
  4. 4. Medical History Review <ul><li>Review/update written medical questionnaire </li></ul><ul><li>Medications </li></ul><ul><li>Allergies </li></ul><ul><li>Need for SBE prophylaxis </li></ul><ul><li>Diabetes </li></ul><ul><li>Pregnancy </li></ul><ul><li>Written consultation with physician as required </li></ul>
  5. 5. Medical History Review <ul><li>SBE Prophylaxis </li></ul><ul><li>Required for endodontic treatment in at risk patients </li></ul><ul><li>AHA recommendations should be followed </li></ul>
  6. 6. Medical History Review <ul><li>Prescribe : </li></ul><ul><ul><li>2 grams Amoxicillin 1 hour prior to treatment </li></ul></ul><ul><ul><li>Clindamycin 600 mg for penicillin allergic patients </li></ul></ul>
  7. 7. Medical History Review <ul><li>Diabetes </li></ul><ul><li>Do not treat uncontrolled diabetics </li></ul><ul><li>Schedule appointment for early morning </li></ul><ul><li>Ensure that patient has had morning insulin and breakfast </li></ul><ul><li>Have a source of sugar readily available </li></ul>
  8. 8. Medical History Review <ul><li>Pregnancy </li></ul><ul><li>Avoid treatment in first and third trimesters </li></ul><ul><li>Keep radiographic exposure to a minimum </li></ul>
  9. 9. Medical History Review <ul><li>Latex Allergy </li></ul><ul><li>Non-latex rubber dam </li></ul><ul><li>Latex-free gloves </li></ul><ul><li>One report of allergy to gutta-percha – no definitive proof that a true allergic reaction occurred </li></ul><ul><li>Consult patient’s allergist </li></ul>
  10. 10. Medical History Review <ul><li>The only systemic contraindications to endodontic therapy are: </li></ul><ul><li>Uncontrolled diabetes </li></ul><ul><li>A very recent myocardial infarct </li></ul>
  11. 11. Subjective History <ul><li>Chief complaint </li></ul><ul><li>In patient’s own words </li></ul><ul><ul><li>“ My tooth hurts when I chew hard foods” </li></ul></ul><ul><ul><li>“ I can’t drink cold soda” </li></ul></ul>
  12. 12. Pain History
  13. 13. Subjective History <ul><li>Pain History </li></ul><ul><ul><li>Location </li></ul></ul><ul><ul><li>Intensity </li></ul></ul><ul><ul><li>Duration </li></ul></ul><ul><ul><li>Stimulus </li></ul></ul><ul><ul><li>Relief </li></ul></ul><ul><ul><li>Spontaneity </li></ul></ul>
  14. 14. Pulpal Pain <ul><li>Very poorly localized </li></ul><ul><ul><li>Intermittent </li></ul></ul><ul><ul><li>Throbbing </li></ul></ul><ul><ul><li>Intensified by heat, cold and sometimes chewing </li></ul></ul><ul><ul><li>May be relieved by cold </li></ul></ul><ul><ul><li>Usually severe </li></ul></ul>
  15. 15. Pulpal Pain
  16. 16. Periradicular Pain <ul><li>May be well localized </li></ul><ul><li>Deep pain </li></ul><ul><li>Intensified by chewing </li></ul><ul><li>Moderate to severe in intensity </li></ul>
  17. 17. Periodontal Pain <ul><li>May be well localized </li></ul><ul><li>Intensified by chewing </li></ul><ul><li>Moderate to severe in intensity </li></ul>
  18. 18. Periradicular /Periodontal Pain
  19. 19. Subjective History <ul><li>Gives rise to tentative diagnosis </li></ul><ul><li>Determines urgency of treatment </li></ul><ul><li>Confirmed by examination and special tests </li></ul>
  20. 20. Objective Testing <ul><li>Visual Examination </li></ul><ul><li>Radiographs </li></ul><ul><li>Percussion </li></ul><ul><li>Palpation </li></ul><ul><li>Mobility </li></ul><ul><li>Thermal tests </li></ul>
  21. 21. Objective Testing <ul><li>Electric Pulp Test </li></ul><ul><li>Periodontal probing </li></ul><ul><li>Selective anesthesia </li></ul><ul><li>Test cavity </li></ul><ul><li>Transillumination </li></ul><ul><li>Occlusion </li></ul>
  22. 22. Visual Examination <ul><li>Extra-oral examination </li></ul><ul><ul><li>Facial asymmetry </li></ul></ul><ul><ul><li>Swelling </li></ul></ul><ul><ul><li>Extra oral sinus tract </li></ul></ul><ul><ul><li>TMJ </li></ul></ul>
  23. 23. Extra-oral Swelling
  24. 24. Visual Examination Extra oral sinus tracts associated with necrotic teeth
  25. 25. Visual Examination <ul><li>Intra-oral examination </li></ul><ul><li>Soft tissue lesions </li></ul><ul><ul><ul><li>Swelling </li></ul></ul></ul><ul><ul><ul><li>Redness </li></ul></ul></ul><ul><ul><ul><li>Sinus tract </li></ul></ul></ul>
  26. 26. Acute apical abscess Acute apical abscess Incision and drainage
  27. 27. Visual Examination A sinus tract should be traced with a gutta-percha cone
  28. 28. Visual Examination <ul><li>Hard tissues </li></ul><ul><li>Caries </li></ul><ul><li>Large or defective restorations </li></ul><ul><li>Discolored/chipped teeth </li></ul>
  29. 29. Discoloration
  30. 30. Radiographs <ul><li>Always take your own pre-operative radiograph </li></ul><ul><li>Never make a diagnosis based on radiographic evidence alone </li></ul>
  31. 31. Radiographs <ul><li>Consider taking a bitewing film of posterior teeth </li></ul><ul><li>Note characteristic appearance of fractured root </li></ul>
  32. 32. Radiographs Characteristic J-shaped or halo lesion associated with fractured root
  33. 33. Percussion Test <ul><li>A very significant test </li></ul><ul><li>Always compare suspect tooth with adjacent and contralateral teeth </li></ul><ul><li>Tenderness indicates inflammation in the PDL </li></ul><ul><li>Cause of inflammation may be pulpal or periodontal </li></ul>
  34. 34. Percussion Test Vertical percussion Horizontal percussion
  35. 35. Percussion Test Tooth Slooth Used to assess cracked teeth and incomplete cuspal fractures
  36. 36. Palpation Test <ul><li>Extraoral </li></ul><ul><ul><li>To detect swollen or tender lymph nodes </li></ul></ul><ul><li>Intraoral </li></ul><ul><ul><li>May detect early periapical tenderness </li></ul></ul><ul><ul><li>Identifies soft tissue swelling </li></ul></ul><ul><ul><li>Must compare with other areas </li></ul></ul>
  37. 37. Palpation
  38. 38. Mobility <ul><li>Reflects the extent of inflammation in the PDL </li></ul><ul><li>Compare with adjacent and contralateral teeth </li></ul><ul><li>There are many causes of mobility besides pulpal inflammation extending into the PDL </li></ul>
  39. 39. Thermal Tests <ul><li>Cold always used </li></ul><ul><li>Heat rarely used </li></ul><ul><li>Compare reaction with adjacent and contralateral teeth </li></ul><ul><li>Refractory period of at least 10 minutes before pulp can be retested accurately </li></ul>
  40. 40. Thermal Tests
  41. 41. Thermal Tests Ice stick CO2 Snow
  42. 42. Thermal Tests <ul><li>Isolate area with cotton rolls </li></ul><ul><li>Dry teeth to be tested </li></ul><ul><li>Ask patient to: </li></ul><ul><ul><li>“ Raise hand on feeling cold” </li></ul></ul><ul><ul><li>“ Lower hand when cold feeling goes away” </li></ul></ul><ul><li>Record: </li></ul><ul><ul><li>+ or – sensitivity to cold </li></ul></ul><ul><ul><li>Time until cold sensitivity was felt </li></ul></ul><ul><ul><li>Time that cold sensitivity lingered </li></ul></ul>
  43. 43. Thermal Tests <ul><li>Classic Responses to Thermal (cold) Testing : </li></ul><ul><li>Normal Pulp : Moderate transient pain </li></ul><ul><li>Reversible Pulpitis : Sharp pain; subsides quickly </li></ul><ul><li>Irreversible pulpitis : Pain lingers </li></ul><ul><li>Necrosis : No response </li></ul><ul><li>(Note false positive and false negative responses common) </li></ul>
  44. 44. Electric Pulp Test <ul><li>A direct test of nerve elements of pulpal tissue </li></ul><ul><li>Vitality versus non-vitality only – not whether vital pulp is normal or inflamed </li></ul><ul><li>In multi-rooted teeth, where one canal is vital – tooth usually tests vital </li></ul><ul><li>False positives and false negatives may occur </li></ul>
  45. 45. Electric Pulp Test <ul><li>False positive reading: </li></ul><ul><li>Electrode contact with metal restoration or gingiva </li></ul><ul><li>Patient anxiety </li></ul><ul><li>Liquefaction necrosis </li></ul><ul><li>Failure to isolate and dry teeth prior to testing </li></ul>
  46. 46. Electric Pulp Test
  47. 47. Electric Pulp Test <ul><li>False negative reading : </li></ul><ul><li>Patient is heavily premedicated </li></ul><ul><li>Inadequate contact between electrode and enamel </li></ul><ul><li>Recently traumatized tooth </li></ul><ul><li>Recently erupted tooth with open apex </li></ul><ul><li>Partial necrosis </li></ul>
  48. 48. Electric Pulp Testing
  49. 49. Periodontal Examination <ul><li>Periodontal probing pocket depths must be measured and recorded </li></ul><ul><li>A significant pocket, in the absence of periodontal disease may indicate root fracture </li></ul><ul><li>Poor periodontal prognosis may be a contraindication to root canal therapy </li></ul>
  50. 50. Periodontal Examination
  51. 51. Periodontal Examination An isolated deep pocket may indicate a root fracture
  52. 52. Selective Anesthesia <ul><li>May help to identify the possible source of pain </li></ul><ul><li>An IDN block can localize pain to one arch </li></ul><ul><li>Ability to anesthetize a single tooth has been questioned </li></ul>
  53. 53. Test Cavity <ul><li>Initiation of cavity preparation without anesthesia </li></ul><ul><li>Test of last resort </li></ul>
  54. 54. Transillumination <ul><li>Helps to identify vertical crown fracture </li></ul><ul><li>Produces light and dark shadows at fracture site </li></ul>
  55. 55. Transillumination A crack will block and reflect the light when transilluminated
  56. 56. Occlusion <ul><li>Hyperocclusion – a possible cause of percussion sensitivity </li></ul>
  57. 57. Analysis <ul><li>Analyze the data gathered via: </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Examination </li></ul></ul><ul><ul><li>Special tests </li></ul></ul><ul><li>Arrive at a clinical (not histologic) diagnosis: </li></ul><ul><ul><li>Pulpal diagnosis </li></ul></ul><ul><ul><li>Periapical diagnosis </li></ul></ul>
  58. 58. Possible Pulpal Diagnoses <ul><li>Normal </li></ul><ul><li>Reversible pulpitis </li></ul><ul><li>Irreversible pulpitis </li></ul><ul><li>Necrosis </li></ul><ul><li>Previous endodontic treatment </li></ul>
  59. 59. Normal Pulp <ul><li>Symptoms None </li></ul><ul><li>Radiograph No periapical change </li></ul><ul><li>Pulp tests Responds normally </li></ul><ul><li>Periapical tests Not tender to percussion or </li></ul><ul><li>palpation </li></ul>
  60. 60. Reversible Pulpitis <ul><li>Symptoms May have thermal sensitivity </li></ul><ul><li>Radiograph No periapical change </li></ul><ul><li>Pulp tests Responds – sensitivity not lingering </li></ul><ul><li>Periapical tests Not tender to percussion or palpation </li></ul>
  61. 61. Irreversible Pulpitis <ul><li>Symptoms May have spontaneous pain </li></ul><ul><li>Radiograph No periapical change </li></ul><ul><li>Pulp Tests Pain that lingers </li></ul><ul><li>Periapical tests Generally not tender to percussion or palpation </li></ul>
  62. 62. Necrotic Pulp <ul><li>Symptoms No thermal sensitivity </li></ul><ul><li>Radiograph Dependent on periapical status </li></ul><ul><li>Pulp tests No response </li></ul><ul><li>Periapical tests Dependent on periapical status </li></ul>
  63. 63. Possible Periapical Diagnoses <ul><li>Normal </li></ul><ul><li>Acute apical periodontitis </li></ul><ul><li>Chronic apical periodontitis </li></ul><ul><li>Chronic apical periodontitis with symptoms </li></ul><ul><li>Acute apical abscess </li></ul><ul><li>Chronic apical abscess </li></ul><ul><li>Condensing osteitis </li></ul>
  64. 64. Normal Periapex <ul><li>Symptoms None </li></ul><ul><li>Radiograph No periapical change </li></ul><ul><li>Pulp tests Responds normally </li></ul><ul><li>Periapical tests Not tender to percussion or palpation </li></ul>
  65. 65. Acute Apical Periodontitis <ul><li>Symptoms Pain on pressure </li></ul><ul><li>Radiograph No periapical change </li></ul><ul><li>Pulp tests +/- depending on pulp status </li></ul><ul><li>Periapical tests Tender to percussion and/or palpation </li></ul>High restorations, traumatic occlusion, orthodontic treatment, cracked teeth, vertical root fractures, periodontal disease and maxillary sinusitis may also produce this response
  66. 66. Chronic Apical Periodontitis <ul><li>Symptoms None </li></ul><ul><li>Radiograph Periapical radiolucency </li></ul><ul><li>Pulp tests No response </li></ul><ul><li>Periapical tests Not tender to percussion or palpation </li></ul>
  67. 67. Chronic Apical Periodontitis with symptoms <ul><li>Symptoms Pain on pressure </li></ul><ul><li>Radiograph Periapical radiolucency </li></ul><ul><li>Pulp tests No response </li></ul><ul><li>Periapical tests Tender to percussion and/or palpation </li></ul>
  68. 68. Acute Apical Abscess <ul><li>Symptoms Swelling and severe pain </li></ul><ul><li>Radiograph +/- periapical radiolucency </li></ul><ul><li>Pulp tests No response </li></ul><ul><li>Periapical tests Tender to percussion and palpation </li></ul>
  69. 69. Chronic apical abscess <ul><li>Symptoms Draining sinus – usually no pain </li></ul><ul><li>Radiograph Periapical radiolucency </li></ul><ul><li>Pulp tests No response </li></ul><ul><li>Periapical tests Not tender to percussion or palpation </li></ul>
  70. 70. Condensing Osteitis <ul><li>Symptoms Variable </li></ul><ul><li>Radiograph Increased bone density </li></ul><ul><li>Pulp tests Dependent on pulp status </li></ul><ul><li>Periapical tests +/- tenderness to percussion and palpation </li></ul>
  71. 71. Treatment Planning <ul><li>Treatment decisions are based on: </li></ul><ul><ul><li>Pulpal diagnosis </li></ul></ul><ul><ul><li>Periapical diagnosis </li></ul></ul><ul><ul><li>Restorability of tooth </li></ul></ul><ul><ul><li>Periodontal considerations </li></ul></ul><ul><ul><li>Difficulty of case </li></ul></ul><ul><ul><li>Financial considerations </li></ul></ul>
  72. 72. Treatment Planning <ul><li>Two major decisions: </li></ul><ul><li>Is root canal therapy indicated? </li></ul><ul><li>Should I carry out this treatment myself or should I refer the case? </li></ul>
  73. 73. Factors that add risk to Endodontic Cases <ul><li>Patient considerations </li></ul><ul><li>Objective clinical findings </li></ul><ul><li>Additional conditions </li></ul>
  74. 74. Patient Considerations <ul><li>Medical history </li></ul><ul><li>Local anesthetic considerations </li></ul><ul><li>Personal factors and general considerations </li></ul>
  75. 75. Objective Clinical Findings <ul><li>Diagnosis </li></ul><ul><li>Radiographic findings </li></ul><ul><li>Pulpal space </li></ul><ul><li>Root morphology </li></ul><ul><li>Apical morphology </li></ul><ul><li>Malpositioned teeth </li></ul>
  76. 76. Additional Conditions <ul><li>Restorability </li></ul><ul><li>Existing restoration </li></ul><ul><li>Fractured tooth </li></ul><ul><li>Resorptions </li></ul><ul><li>Endo-perio lesions </li></ul><ul><li>Trauma </li></ul><ul><li>Previous endodontic treatment </li></ul><ul><li>Perforations </li></ul>
  77. 77. AAE Case Difficulty Assessment Form <ul><li>Rate the risk presented by each factor as: </li></ul><ul><ul><li>Average – 1 </li></ul></ul><ul><ul><li>High – 2 </li></ul></ul><ul><ul><li>Extreme – 3 </li></ul></ul><ul><li>A case with all average ratings should be fairly straightforward </li></ul>
  78. 78. AAE Case Difficulty Assessment Form
  79. 79. AAE Case Difficulty Assessment Form <ul><li>If one or more factors present high or extreme risk, one must plan how to manage this extra risk prior to initiating treatment </li></ul>
  80. 80. Presenting complaint <ul><li>“ I had a crown placed about 6 years ago and now but I have a blister over that tooth” </li></ul>
  81. 81. Dental History/History of presenting complaint <ul><li>The patient reports no pain at any stage. She first noted the “blister” over tooth #14 about two weeks ago </li></ul>
  82. 82. Medical History <ul><li>Allergy to penicillin </li></ul><ul><li>Aspirin upsets pt’s stomach </li></ul>
  83. 83. Subjective history <ul><li>No subjective symptoms </li></ul><ul><li>Pt reports presence of ‘blister’ on gum </li></ul>
  84. 84. Examination <ul><li>Extra-oral examination </li></ul><ul><ul><li>No facial asymmetry </li></ul></ul><ul><ul><li>No cervical lymphadenopathy </li></ul></ul><ul><ul><li>No muscle or joint tenderness </li></ul></ul><ul><li>Intra-oral examination </li></ul><ul><ul><li>Sinus present buccal to #14 </li></ul></ul>
  85. 85. Special tests <ul><li>Tooth #14 not tender on palpation </li></ul><ul><li>Pus can be expressed from sinus tract </li></ul><ul><li>No abnormal mobility </li></ul><ul><li>Periodontal probing 6 mm on DP; in the 4 – 5 mm range elsewhere </li></ul>
  86. 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. 87. Pre-operative film
  88. 88. Diagnosis <ul><li>Pulpal necrosis </li></ul><ul><li>Chronic apical abscess </li></ul><ul><li>RCT and restoration </li></ul><ul><li>Medical history does not affect treatment plan </li></ul>
  89. 89. Access and Working length
  90. 90. Completed RCT
  91. 91. Summary <ul><li>Pulpal Diagnoses </li></ul><ul><li>Normal </li></ul><ul><li>Reversible pulpitis </li></ul><ul><li>Irreversible pulpitis </li></ul><ul><li>Necrosis </li></ul>
  92. 92. Summary <ul><li>Periapical Diagnoses </li></ul><ul><li>Normal </li></ul><ul><li>Acute periradicular periodontitis </li></ul><ul><li>Chronic periradicular periodontitis </li></ul><ul><li>Acute apical abscess </li></ul><ul><li>Chronic apical abscess </li></ul><ul><li>Condensing osteitis </li></ul>
  93. 93. Summary <ul><li>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 </li></ul>
  94. 94. Summary <ul><li>Treatment Planning </li></ul><ul><li>Root canal therapy is indicated in situations in which the pulp cannot recover: </li></ul><ul><ul><li>Irreversible pulpitis </li></ul></ul><ul><ul><li>Pulpal necrosis </li></ul></ul>
  95. 95. Summary <ul><li>Following root canal therapy </li></ul><ul><li>Posterior teeth must be restored with a crown. </li></ul><ul><li>A post may be required if there is insufficient tooth structure to retain a core </li></ul><ul><li>Anterior teeth may not require a full coverage restoration </li></ul>

×