Transcript Lesson 2
Clinical Diagnostic Procedures Ch #4 Diagnosis & Tx Planning Training in Basic Science enables: – Perform diagnostic tests – Interpret test results differentially – Psychologically manage patient during testing – Formulate diagnosis and treatment plan. Systematic Approach to diagnosis 1. 2. 3. 4. 5. Ascertain chief complaint Take relevant medical and dental history Conduct thorough SubjectiveObjective- Radiographic examinations Analyze the data obtained Formulate appropriate diagnosis Scope of Endodontics Vital Pulp therapy Nonsurgical RCT Endo Surgery Retreatment Hemisection-Root Amputation Bleaching Intentional replantation Endodontic Endosseous implants Apexification Apexogenesis Transplantation Treatment of trauma Perio-endo pathosis Ortho-endodontics Graduating General Dentist Should be very skilled in diagnosis and treatment planning over a broad base Should know when to consult and refer. Systematic Approach to diagnosis 1. Ascertain chief complaint Diagnosis 1. Chief Complaint – – – – First information obtained Problem expressed in patient’s own words Recorded in non-technical language If referred may be “No CC” Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM) © 2005 Elsevier Diagnosis 1. 2. Ascertain chief complaint Take relevant medical and dental history 2. Health History – Comprehensive for new patients – Update data of prior patients Demographic data Medical History Current Medications Dental History Chief complaint Present illness Demographic data Identify Pt characteristics Medical History There are no absolute C/I to endodontics Endodontics is less traumatic than extraction Older patients are in need of RCT Cases that need precautionary measures When consultations are needed Current Medications List medications as presented by patient Review C/I and precautionary measures Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM) © 2005 Elsevier Dental History Pay attention to state of patient Ask probing questions Establish good rapport and caring attitude. Diagnosis 1. 2. 3. Ascertain chief complaint Take relevant medical and dental history Conduct thorough SubjectiveObjective- Radiographic examinations 1.Subjective Examination Present Illness Pain Tentative diagnosis Present Illness Only if a patient has a sign problem If no sign symptoms go on to objective tests Pain may affect pt;s psychology Dr must be open, caring, and interested to elicit the most info Ask further probing questions Reiterate to the patient what they said in a clear manner. Pain Intensity – Intense irreversible pathosis – Recent, not long standing – Unrelieved by analgesic – Intermittent – Irreversible pulpitis – Acute apical periodontisits or abscess Spontaneous pain – Without eliciting stimulus – Awakens patient – May be relieved by cold – Usually irreversible pulpitis Continuous pain – Lingering type of pain after removal of stimulus – Continuous pain with thermal stimulus= irreversible pulpitis – Continuous pain after application of pressure = periradicular pathosis Tentative diagnosis Careful subjective questions Rule out non-odontogenic causes Urgency of treatment determined Confirmed or denied by hands-on oral examination and clinical tests. 2.Objective Examination Extraoral examination – – – – – – – – – General appearance skin tone Facial asymmetry Swelling Discoloration Redness Extraoral scars Sinus tracts Tender or enlarged lymph nodes Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM) © 2005 Elsevier Intraoral examination – Soft tissue: Lips-Oral mucosa- Cheeks- Tongue- PalateMuscles – Alveolar mucosa & attached gingiva Discoloration Inflammation Ulceration Sinus tract formation – Dentition Discoloration Fractures Abrasions Erosions Caries Large restorations Clinical tests Complex Process Tests of patients response! Presence of limitations May be inconclusive Supplementary confirmatory tests needed False-neg + False-pos Control teeth Periapical tests Percussion Palpation – Indicative of periradicular inflamation Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM) © 2005 Elsevier Pulp vitality tests Cold tests Direct dentin stimulation Heat tests Electric pulp testing Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM) © 2005 Elsevier Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM) © 2005 Elsevier Periodontal Examination Probing Mobility Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM) © 2005 Elsevier 3.Radiographic examination Periapical lesions (of odontogenic origin): – LD is lost apically – Angulation does not change position – Lucency resembles a hanging drop – Usually cause of necrosis is evident – Condensing ostietis- enostosis Pulpal lesions Special tests Caries removal Selective anesthesia Transillumination Sinus tract tracing Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM) © 2005 Elsevier Diagnosis and Tx Plans Normal or reversible pulpitis – Remove cause Irreversible pulpitis – RCT Necrosis Treatment choices Routine cases Difficult Procedures – Complications – Adjunctive procedures Prognosis Systematic Approach to diagnosis 1. 2. 3. 4. Ascertain chief complaint Take relevant medical and dental history Conduct thorough SubjectiveObjective- Radiographic examinations Analyze the data obtained Diagnosis Pulpal: – Normal – Reversible – Irreversible – Necrotic – Extirpated Periapical – Normal – Acute Apical Periodontitis – Chronic Apical Periodontitis – Acute Apical Abscess – Chronic Apical Abscess – Condensing Ostietis Diagnosis symptoms radiographic pulp tests PA tests Treatment Normal None None Responds Not sensitive None (unless intentional) None Reversible Pulpitis may or may not have slight symptoms to theraml stimuli No PA changes Responds Not sensitive None (unless intentional) Remove cause Irreversible Pulpitis may or may not have slight symptoms to thermal stimuli may have spontaneous or severe pain to thermal stimuli No PA changes condensing ostetis Responds may have severe pain on stimulus may or may not have pain on percussion and palpation RCT Pulpotomy, pulpectomy Extraction Necrosis None PA PA No response PA RCT Extraction None None Responds Not sensitive None (unless intentional) None Pain on mastication or pressure None Response No response Pain on percussion or palpation RCT Apical radiolucency No response None Mild pain on percussion or palpation RCT Usually RL lesion No response Pain on percussion Debridement Draining Pulpal Periapical Normal Acute Apical Periodontitis Chronic apical periodontitis Acute Apical Abscess None mild Swelling Significant pain Chronic Apical abscess Draining sinus Usually RL lesion No response None RCT Condensing Osteitis variable Increase bone density Variable Variable Variable Difficult diagnosis Longitudinal fratures Cracked tooth Stressed tooth Treatment Planning To treat or not to treat Treatment related to diagnosis Number of appointments Prognosis Assess difficulty of case Refer when needed 422 RDS Clinical Endodontic Form Serial No.: __________ _________ Case No.: Student's Name: File No.: Patient's Name: Age: __________ Telephone No.: (W)______________ _________ Exam Date:________________ Sex: ______________ Tooth No.: _______________ Chief Complaint: DIAGN OSTIC TESTS : PAIN: CLINICAL EXAM: None Swelling (intra/extraoral) Vague Pain THERAPY: Test Result (soft/hard/fluctuant) Tooth Caries control Vital pulp therapy Pain to heat/cold Cellutitis Cold Apexification Pain to sweet/sour Sinus tract Hot Root canal therapy Pain to mastication Regional lymphadenopathy EPT Root canal retreatment Spontaneous/on stimulus Poor oral hygiene Percussion Surgical endodontics Intermitten/continuous Perio pocket ( Palpation Extraction Localized/diffused/radiating Mobility (I/II/III) Test Cavity Others: Severe/moderate/mild Caries Probing Depth Duration: sec./mins./hrs. Restoration (minimal/large) mm) Discoloration MEDICAL ALERT: Crown fracture (class: Rheumatic fever Tooth (canal) already opened ) Rheumatic heart disease High blood pressure Drug allergy ( = Normal AB = Abnormal NR = No Response Faculty Comments: LR = Lingered Response RADIOGRAPHIC EXAM: ) Faculty Signature: N NLR = Nonlingered Response Normal Hepatitis/tuberculosis Widen/thickened PDL DIAGNOSIS: Pregnancy Apical/lateral rarefaction a) Others: Internal/external resorption Normal Caries Reversible pulpitis REASON FOR TREATMENT: Calcification/pulp stone Irreversible pulpitis Carious exposure Root fracture (H/V) Necrosis of pulp Mechanical exposure Furcation involvement Elective endo treatment Open apex Trauma Incomplete RCT Normal Perio Broken instrument Acute apical periodontitis Cracked tooth Perforation Chronic apical periodontitis Endo previously initiated Others: Acute apical abscess Pulpal Already Started b) Periapical Overdenture Chronic apical abscess Others: Condensing osteitis Start Check: Date: Signature: Name: Number of canals Total Points for all canals Points per canal Extra Procedure points Total Points for case Computer No.: ________________________ GUIDELINES FOR EVALUATION Session Procedures - No instructor's permission/sign 0 + suspension - No or improper Diagnosis -2.5 History, Examination, Diagnosis - No or improper RD isolation Failure/ -2.5 Patient management/LA - Improper patient management -2.5 Isolation - Ineffective LA -2.5 Access cavity ACCESS 1 2 3 Signature 4 5 6 N/A Working length - Under-extended -1.5 Instumentation - Over-extended -2.5 Obturation - Improper location/gouging -3 Special Procedures - Perforation 0 Special Procedures WL Knowledge - Improper size -3 - Under/over ext. >2mm -3 INSTRUM. MAC Time Management TOTAL GRADE [Faculty]: - Improper MAF -3 - Apical perforation -3 - Stripping perforation 0 - Broken instrument 0 - Flush -3 - Not flared -3 Signature: Course Director's Grade: FINAL GRADE [out of 10]: Root Canal Signature: Int WL Ref. Point S WL L S MAF L S MC L S OBTURATION - Short -3 - Over-extended GP -3 - Sealer ext. -1 - Voids apically -3 - Voids middle/coronal -1.5 - Flush -2 - No intermediate RG -3 - No final RG -3 - No final resto -5 - Treating wrong tooth 0 + suspension Guarded - No medical history 0 + suspension Surgery Recall Examination Prognosis Findings Date Clinical Good Radiographic Poor Likely Comments: Faculty's Grade: L Sample Clinical Notes 20 year old female patient CC: “ I have a swelling and broken down tooth in my mouth” points to URQ Med Hx: Juvenile Diabetes – controlled with medication (Insulin Injections 2X/day) Dent Hx: Several extractions, fillings, and RCT Pain: in URQ started 2 weeks ago, wakes her up at night. Continuous, throbbing, is not relieved by analgesics, increases especially when drinking cold and pain continues after removal of the stimulus. EOE: NAD IOE: NAD tissues, large caries lesion in #16 Tests: #16: – Pain on perc + palp – Severe lingering pain with Ice test (Endo frost) – Early response with EPT – No pockets – No mobiliy Rad: small PA RL related to apex of #16 Diag: Irreversible pulpitis with chronic PA periodontitis Tx plan: RCT, P+C, PFM Crown Tx today: – IDNB 2% lidocaine – 2 carpules – Isolation – Caries excavation – Access – Filing and irrigation MB 19.5 mm 30 k DB 19.5 mm 30 k P 21 mm 40 k Dry canals Cotton pellet cavit Reference Principles & Practice of Endodontics 3rd ed (2002) Walton & Torabinejad Ch # 4 Homework 1. 2. Write a table (or mind map) outlining medical conditions that may contraindicate or alter endodontic therapy Outline clinical endodontic tests in a thorough, logical manner (tables or mindmaps can be used) Next week’s lecture Isolation Radiography Access Preparation & Length determination Cleaning & Shaping Obturation Ch.8 Ch. 9 Ch. 12 Ch. 13 Ch. 14 Clinic Attendance sheet will be removed after 15 mns You will have 2 patients each to examine and fill out endo forms. Your instructor will show you how to perform clinic tests for the whole group Don’t forget to sign evaluation forms Sign and dismiss patient @ 4:30 pm PROMPTLY