Transcript 14. Treatment of different forms of periodontitis

Treatment of different forms of
periodontitis Diagnosis and
Treatment Planning
Definition
Diagnosis is the determination of the
nature of a diseased condition by
careful investigation of its symptoms
and history
Sequence of Events
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Medical History Review
Subjective History
Objective Testing
Analysis of data collected – Clinical diagnosis
Plan of Action
Medical History Review
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Review/update written medical questionnaire
 Medications
 Allergies
 Diabetes
 Pregnancy
 Written consultation with physician as required
Medical History Review
Diabetes
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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
Medical History Review
Pregnancy
 Avoid treatment in first and third
trimesters
 Keep radiographic exposure to a
minimum
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
Medical History Review
The only systemic contraindications to
endodontic therapy are:
 Uncontrolled diabetes
 A very recent myocardial infarct
Subjective History
Chief complaint
 In patient’s own words
“My tooth hurts when I chew hard foods”
 “I can’t drink cold soda”
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Pain History
Subjective History
Pain History
Location
 Intensity
 Duration
 Stimulus
 Relief
 Spontaneity
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Pulpal Pain
Very poorly localized
Intermittent
 Throbbing
 Intensified by heat, cold and sometimes
chewing
 May be relieved by cold
 Usually severe
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Pulpal Pain
Periradicular Pain
 May
be well localized
 Deep pain
 Intensified by chewing
 Moderate to severe in intensity
Periodontal Pain
May be well localized
 Intensified by chewing
 Moderate to severe in intensity
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Periradicular /Periodontal Pain
Subjective History
Gives rise to tentative diagnosis
 Determines urgency of treatment
 Confirmed by examination and special
tests
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Objective Testing
Visual Examination
 Radiographs
 Percussion
 Palpation
 Mobility
 Thermal tests
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Objective Testing
Electric Pulp Test
 Periodontal probing
 Selective anesthesia
 Test cavity
 Transillumination
 Occlusion
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Visual Examination
 Extra-oral
 Facial
examination
asymmetry
 Swelling
 Extra oral sinus tract
Extra-oral Swelling
Visual Examination
Extra oral sinus tracts
associated with
necrotic teeth
Visual Examination
Intra-oral examination
 Soft
tissue lesions
 Swelling
 Redness
 Sinus
tract
Acute apical abscess
Acute apical abscess
Incision and drainage
Visual Examination
A sinus tract should
be traced with a
gutta-percha cone
Visual Examination
Hard tissues
 Caries
 Large
or defective restorations
 Discolored/chipped teeth
Discoloration
Radiographs
Always take your own pre-operative
radiograph
 Never make a diagnosis based on
radiographic evidence alone
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Radiographs
Consider taking a bitewing film of
posterior teeth
 Note characteristic appearance of
fractured root
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Radiographs
Characteristic J-shaped or halo lesion associated with
fractured root
Percussion Test
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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
Percussion Test
Vertical percussion
Horizontal percussion
Percussion Test
Tooth Slooth
Used to assess cracked teeth and
incomplete cuspal fractures
Palpation Test
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Extraoral
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To detect swollen or tender lymph nodes
Intraoral
May detect early periapical tenderness
 Identifies soft tissue swelling
 Must compare with other areas
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Palpation
Mobility
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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
Thermal Tests
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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
Thermal Tests
Thermal Tests
CO2 Snow
Ice stick
Thermal Tests
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Isolate area with cotton rolls
 Dry teeth to be tested
 Ask patient to:
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“Raise hand on feeling cold”
“Lower hand when cold feeling goes away”
Record:
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+ or – sensitivity to cold
Time until cold sensitivity was felt
Time that cold sensitivity lingered
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)
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Electric Pulp Test
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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
Electric Pulp Test
False positive reading:
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Electrode contact with metal restoration or gingiva
Patient anxiety
Liquefaction necrosis
Failure to isolate and dry teeth prior to testing
Electric Pulp Test
Electric Pulp Test
False negative reading:
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Patient is heavily premedicated
Inadequate contact between electrode and enamel
Recently traumatized tooth
Recently erupted tooth with open apex
Partial necrosis
Electric Pulp Testing
Periodontal Examination
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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
Periodontal Examination
Periodontal Examination
An isolated deep pocket may indicate a root fracture
Selective Anesthesia
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May help to identify the
possible source of pain
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Ability to anesthetize a
single tooth has been
questioned
Test Cavity
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Initiation of cavity preparation without
anesthesia
 Test of last resort
Transillumination
Helps to identify vertical crown
fracture
 Produces light and dark shadows at
fracture site
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Transillumination
A crack will block and reflect the light when transilluminated
Occlusion
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Hyperocclusion – a possible cause
of percussion sensitivity
Analysis
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Analyze the data gathered via:
 History
 Examination
 Special tests
 Arrive at a clinical (not histologic) diagnosis:
 Pulpal diagnosis
 Periapical diagnosis
Possible Pulpal Diagnoses
Normal
 Reversible pulpitis
 Irreversible pulpitis
 Necrosis
 Previous endodontic treatment
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Normal Pulp
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Symptoms
Radiograph
Pulp tests
Periapical tests
None
No periapical change
Responds normally
Not tender to percussion or
palpation
Reversible Pulpitis
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Symptoms
Radiograph
Pulp tests
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Periapical tests
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May have thermal sensitivity
No periapical change
Responds – sensitivity not
lingering
Not tender to percussion or
palpation
Irreversible Pulpitis
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Symptoms
Radiograph
Pulp Tests
Periapical tests
May have spontaneous pain
No periapical change
Pain that lingers
Generally not tender to
percussion or palpation
Necrotic Pulp
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Symptoms
 Radiograph
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Pulp tests
 Periapical tests
No thermal sensitivity
Dependent on
periapical status
No response
Dependent on
periapical status
Possible Periapical Diagnoses
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Normal
Acute apical periodontitis
Chronic apical periodontitis
Chronic apical periodontitis with symptoms
Acute apical abscess
Chronic apical abscess
Condensing osteitis
Normal Periapex
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Symptoms
 Radiograph
 Pulp tests
 Periapical tests
None
No periapical change
Responds normally
Not tender to
percussion or palpation
Acute Apical Periodontitis
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Symptoms
Radiograph
Pulp tests
Periapical tests
Pain on pressure
No periapical change
+/- depending on pulp status
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
Chronic Apical Periodontitis
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Symptoms
 Radiograph
 Pulp tests
 Periapical tests
None
Periapical radiolucency
No response
Not tender to
percussion or palpation
Chronic Apical Periodontitis with
symptoms
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Symptoms
 Radiograph
 Pulp tests
 Periapical tests
Pain on pressure
Periapical radiolucency
No response
Tender to percussion
and/or palpation
Acute Apical Abscess
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Symptoms
Radiograph
Pulp tests
Periapical tests
Swelling and severe pain
+/- periapical radiolucency
No response
Tender to percussion and
palpation
Chronic apical abscess
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Symptoms
 Radiograph
 Pulp tests
 Periapical tests
Draining sinus – usually no pain
Periapical radiolucency
No response
Not tender to percussion or
palpation
Condensing Osteitis
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Symptoms
 Radiograph
 Pulp tests
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Periapical tests
Variable
Increased bone density
Dependent on pulp
status
+/- tenderness to percussion
and palpation
Treatment Planning
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Treatment decisions are based on:
Pulpal diagnosis
 Periapical diagnosis
 Restorability of tooth
 Periodontal considerations
 Difficulty of case
 Financial considerations
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Treatment Planning
Two major decisions:
Is root canal therapy indicated?
 Should I carry out this treatment
myself or should I refer the case?
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Factors that add risk to Endodontic Cases
Patient considerations
 Objective clinical findings
 Additional conditions
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Patient Considerations
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Medical history
 Local anesthetic considerations
 Personal factors and general considerations
Objective Clinical Findings
Diagnosis
 Radiographic findings
 Pulpal space
 Root morphology
 Apical morphology
 Malpositioned teeth
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Additional Conditions
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Restorability
Existing restoration
Fractured tooth
Resorptions
Endo-perio lesions
Trauma
Previous endodontic treatment
Perforations
AAE Case Difficulty Assessment Form
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Rate the risk presented by each factor as:
Average – 1
 High – 2
 Extreme – 3
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A case with all average ratings should be
fairly straightforward
AAE Case Difficulty Assessment Form
Case Difficulty Assessment Form
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If one or more factors present high or
extreme risk, one must plan how to
manage this extra risk prior to initiating
treatment
Presenting complaint
“ I had a crown placed about 6 years ago
and now but I have a blister over that
tooth”
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
Medical History
Allergy to penicillin
 Aspirin upsets pt’s stomach
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Subjective history
No subjective symptoms
 Pt reports presence of ‘blister’ on gum
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Examination
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Extra-oral examination
No facial asymmetry
 No cervical lymphadenopathy
 No muscle or joint tenderness
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Intra-oral examination
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Sinus present buccal to #14
Special tests
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Tooth #14 not tender on palpation
Pus can be expressed from sinus tract
No abnormal mobility
Periodontal probing 6 mm; in the 4 – 5
mm range elsewhere
Special tests
Tooth #
13
Percussion Negative
14
15
3
Negative
Negative
Negative
Thermal
Normal
No
response
Normal
Normal
EPT
56
No
response
Not
possible
to test
49
Pre-operative film
Diagnosis
Pulpal necrosis
 Chronic apical abscess
 RCT and restoration
 Medical history does not affect treatment
plan
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Access and Working length
Completed RCT
Summary
Pulpal Diagnoses
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Normal
 Reversible pulpitis
 Irreversible pulpitis
 Necrosis
Summary
Periapical Diagnoses
 Normal
 Acute periradicular periodontitis
 Chronic periradicular periodontitis
 Acute apical abscess
 Chronic apical abscess
 Condensing osteitis
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
Summary
Treatment Planning
 Root canal therapy is indicated in
situations in which the pulp cannot
recover:
Irreversible pulpitis
 Pulpal necrosis
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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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