Transcript EndoDontic Diagnosis

Medical
History
B. Retamozo DDS, MSD
Department of Endodontics
› Endodontic diagnostic testing should be
performed on all patients in which endodontic
treatment is anticipated
› Diagnosis is done before administering
anesthetic
› Duplicate symptoms by performing clinical
exam and vitality tests
› Develop a pulpal and a periapical diagnosis
› Assemble facts
– Chief complaint
– Medical history
– Dental history
– History of the present condition
– Objective exam
› Interpret the clues
› Differential diagnosis
› Final diagnosis
› The history of the symptoms stated in the patient’s
own words.
› Can the patient point to where they think the pain is?
– Can the patient reproduce symptoms by pressing on
tooth?
› Majority of patients are older with complex medical
problems
› Antibiotic premedication requirement
› Are they on any pain medications?
› Conditions that may present as tooth pain
– Sinusitis
– Clenching, bruxing
– Angina
› Bisphosphonates
› How long?
› How much has it been bothering patient?
– Any medications?
› Does any specific activity precipitate painful episode?
– Chewing
› Prevent sleep?
› Recent dental work
–
–
–
–
Cleaning
Fillings
Crowns
Root Canal Therapy
› Recent trauma
› Soft tissue
– Pain to palpation
– Swelling
– Sinus tract
– Lymph node enlargement
› Dentition
– Caries
– Discolorations
– Fractures
– Abrasions
Acute
Initial Tissue damage
Fast Process
Painful Response
Chronic
Long term tissue damage
Slow process
Lower Response
› Use adjacent teeth
› Localize within an arch
› Use contra-lateral teeth
› You are assessing the patient’s response to a
stimulus
› Vitality Tests
– Rely on the stimulation of Aδ fibers
– Pain is caused by vital pulp tissue
› Thermal
– Test multiple teeth
– Inexpensive
– Cold
› -70°C elicits pain in acute pulpitis
– Heated Gutta percha
› Electric pulp test
– Small electrical charge that gradually
increases
– Only tells you if pulp is vital
› Good for calcified teeth
› Can’t be used for crowned teeth
– False positives
› Nerve fibers in the periodontium
› Partially necrotic teeth with multiple roots
› Necrotic pulp indicators
– Swelling
– Drainage
› Tracking with gutta percha
Normal
Pulp
Reversible
Pulpitis
Irreversible
Pulpitis
Necrotic
Pulp
› Percussion
› Biting pressure
› Palpation
› Response indicates the involvement of the
PDL
– Degree of response is directly proportional to the
degree of inflammation
– Chronic periapical inflammation is often negative
Sw elli ng
Symptomatic
Apical
Periodontitis
Acute
Apical
Abscess
Swelling
Drainage
Sinus Tract
Asymptomatic
Apical
Periodontitis
Chronic
Apical
Abscess
› Radiolucencies
› Caries
– Restorability
› Radiolucencies
› Caries
– Restorability
› Periodontal disease
› Necessary for determining pulpal anatomy prior to
access
› Mobility
– Indicates the integrity of the attachment apparatus
› PPD’s
› Tooth Slooth
› Transillumination
› One piece of the puzzle won’t lead to a correct
diagnosis
› All the data must be considered as a whole to
get a clear picture of the problem
› Normal
› Reversible Pulpitis
› Irreversible Pulpitis
› Necrotic
› Previously initiated
› Previously treated
› Normal Pulp
– Responds to cold, but no pain
– Responds to EPT
› Reversible Pulpitis
– Exaggerated response to cold, but pain does
not linger
– Responds to EPT
– Sensitive to Sweets
› Irreversible Pulpitis
–
–
–
–
Pain to cold that lingers
May or may not have pain to heat
Spontaneous intermittent pain
Constant pain
› Necrotic Pulp
–
–
–
–
No cold response, it may relieve pain
May or may not have heat response
No response to EPT
Spontaneous, intermittent or constant pain
› Normal
› Symptomatic Apical Periodontitis
› Asymptomatic Apical Periodontitis
› Acute Apical Abscess
› Chronic Apical Abscess
› Pulpal Dx:
– Irreversible Pulpitis
› Apical Dx:
– Symptomatic apical
Periodontitis
› Plan: RCT
Tooth #
Cold
Hot
Percussion
EPT
PPD’s
29
+
-
-
23
WNL
30
+++
-
+
21
WNL
31
+
-
-
32
WNL
› Pulpal Dx:
– Necrotic
› Apical Dx:
– Symptomatic apical
Abscess
› Plan: RCT
Tooth #
Cold
Hot
Percussion
EPT
PPD’s
18
-
-
+++
N/A
WNL
19
N/A
N/A
N/A
N/A
N/A
20
+
-
-
N/A
WNL
Large buccal swelling present#18
13 Month Follow-up