Chapter 1: Diagnosis Flashcards
Dental _____ that also allows the patient to record pain experience in an organized and descriptive manner.
history form
T/F: For future reference and in order to ascertain a correct diagnosis, the patient’s chief complaint should be properly documented, using the patient’s own words.
True
The clinician should evaluate a patient’s response to the health questionnaire from what two perspectives?
(1) those medical conditions and current medications that will necessitate altering the manner in which dental care will be provided
and
(2) those medical conditions that may have oral manifestations or mimic dental pathosis.
What cardiovascular conditions would warrant modifications of dental care or treatment?
Cardiovascular: High- and moderate-risk categories of endocarditis, pathologic heart murmurs, hypertension, unstable angina pectoris, recent myocardial infarction, cardiac arrhythmias, poorly managed congestive heart failure.
What pulmonary conditions would warrant modifications of dental care or treatment?
Chronic obstructive pulmonary disease, asthma, tuberculosis
What GI and renal conditions would warrant modifications of dental care or treatment?
End-stage renal disease; hemodialysis; viral hepatitis (types B, C, D, and E); alcoholic liver disease; peptic ulcer disease; inflammatory bowel disease; pseudomembranous colitis
What hematologic conditions would warrant modifications of dental care or treatment?
Sexually transmitted diseases, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), diabetes mellitus, adrenal insufficiency, hyperthyroidism and hypothyroidism, pregnancy, bleeding disorders, cancer and leukemia, osteoarthritis and rheumatoid arthritis, systemic lupus erythematosus.
What neurologic conditions would warrant modifications of dental care or treatment?
Cerebrovascular accident, seizure disorders, anxiety, depression and bipolar disorders, presence or history of drug or alcohol abuse, Alzheimer disease, schizophrenia, eating disorders, neuralgias, multiple sclerosis, Parkinson disease.
Several medical conditions have oral manifestations, which must be carefully considered when attempting to arrive at an accurate dental diagnosis. Why?
Many of the oral soft-tissue changes that occur are more related to the medications used to treat the medical condition rather than to the condition itself.
More common examples of medication side effects are stomatitis, xerostomia, petechiae, ecchymoses, lichenoid mucosal lesions, and bleeding of the oral soft tissues.
What condition involvement of the cervical and submandibular lymph nodes can lead to a misdiagnosis of lymph node enlargement secondary to an odontogenic infection?
tuberculosis
Immunocompromised patients and patients with uncontrolled ____________ respond poorly to dental treatment and may exhibit recurring abscesses in the oral cavity that must be differentiated from abscesses of dental origin.
diabetes mellitus
Patients with iron deficiency anemia, pernicious anemia, and leukemia frequently exhibit what condition of the oral soft tissues?
paresthesia
_________ therapy to the head and neck region can result in increased sensitivity of the teeth and osteoradionecrosis.
Radiation
Multiple myeloma can result in unexplained _____ of teeth.
mobility
What condition is a common condition that may create diagnostic confusion because it may mimic tooth pain in the maxillary posterior quadrant?
Acute maxillary sinusitis - in this situation the teeth in the quadrant may be extremely sensitive to cold and percussion, thus mimicking the signs and symptoms of pulpitis.
The dental history is divided into what five basic directions of questioning?
- localization
- commencement
- intensity
- provocation or attenuation
- duration
“Can you point to the offending tooth?” refers to which dental basic direction of questioning?
localization
“When did the symptoms first occur?” refers to which dental basic direction of questioning?
commencement
“On a scale from 1 to 10, with 10 the most severe, how would you rate your symptoms?” would be an example of which dental basic direction of questioning?
intensity
T/F: Pain is now considered a standard vital sign.
true
Documenting pain intensity (scale of 0 to 10) provides a baseline for what?
comparison after treatment
“What produces or reduces the symptoms?” refers to which dental basic direction of questioning?
provocation or attenuation
T/F: Patients who are using narcotic as well as non-narcotic (e.g., ibuprofen) analgesics may respond differently to questions and diagnostic tests, thereby altering the validity of diagnostic results.
true
“Do the symptoms subside shortly, or do they linger after they are provoked?” refers to which dental basic direction of questioning?
duration
During extraoral examination, palpation allows the clinician to determine what?
Palpation allows the clinician to determine whether the swelling is localized or diffuse, firm or fluctuant.
Palpation of the cervical and submandibular lymph nodes is an integral part of the examination protocol. If the nodes are found to be _______ and _________ along with facial swelling and an elevated temperature, there is a high probability that an infection is present.
firm and tender
T/F: Extraoral facial swelling of odontogenic origin typically is the result of endodontic etiology because diffuse facial swelling resulting from a periodontal abscess is common.
false (rare)
A subtle visual change such as loss of definition of the nasolabial fold on one side of the nose may be the earliest sign of what type of infection?
canine space infection
Extremely long maxillary central incisors also may be associated with a canine space infection, but most extraoral swellings associated with the maxillary centrals express themselves as a swelling of the ____________.
upper lip and base of the nose
Swelling of the upper lip and the loss of definition of the nasolabial fold on the patient’s left side, which indicates infection where?
early canine space infection
Swelling of the left side of the face extending into and involving the left eye indicates infection where?
canine space infection
If the _____ space becomes involved, the swelling will be extraoral in the area of the posterior cheek
buccal
These swellings in ____ space are generally associated with infections originating from the buccal root apices of the maxillary premolar and molar teeth and the mandibular premolar and first molar teeth.
buccal space
Extraoral swelling associated with mandibular incisors will generally exhibit itself in the _____ or ______ space.
submental, submandibular
T/F: Sinus tracts of odontogenic origin may also open through the skin of the face and will generally close once the offending tooth is treated and healing occurs.
true
Many patients with ____________ give a history of being treated by general physicians, dermatologists, oncologists, or plastic surgeons with systemic or topical antibiotics or surgical procedures in attempts to heal the extraoral stoma. In these particular cases, after multiple treatment failures, the patients may finally be referred to a dental clinician to determine whether there is a dental cause.
extraoral sinus tracts
What does the image indicate?
intraoral sinus tract
What does the image indicate?
extraoral sinus tract
Intraoral swellings should be visualized and palpated to determine whether they are _______ or _______ and whether they are firm or fluctuant.
diffuse/localized
Swelling in the anterior part of the palate is most frequently associated with an infection present at the apex of which teeth?
maxillary lateral incisor or the palatal root of the maxillary first premolar
Fluctuant swelling in the posterior palate associated with periradicular disease from which tooth?
palatal root of the maxillary first molar
Intraoral swelling can also occur in the sublingual space if the infection from the root apex spreads to the lingual and exits the alveolar bone superior to the attachment for the mylohyoid muscle. The tongue will be elevated and the swelling will be _____ because the sublingual space is contiguous with no midline separation.
bilateral
If the infection exits the alveolar bone to the lingual with mandibular molars and is inferior to the attachment of the mylohyoid muscle, the swelling will be noted in what space?
submandibular space
Intraoral swelling present in what space can result from an infection associated with the apex of the root of any maxillary tooth that exits the alveolar bone on the facial aspect and is inferior to the muscle attachment present in that area of the maxilla?
mucobuccal fold (maxillary)
Intraoral swelling present in what space from an infection associated with the mandibular teeth if the root apices are superior to the level of the muscle attachments and the infection exits the bone on the facial?
mucobuccal fold (mandibular)
Severe infections involving the maxillary and mandibular molars can extend into the __________ space, resulting in intraoral swelling of the tonsillar and pharyngeal areas.
parapharyngeal
Infection in what space can be life threatening if the patient’s airway becomes obstructed?
parapharyngeal
On occasion, a chronic endodontic infection will drain through an intraoral communication to the gingival surface and is known as a ________.
sinus tract
A sinus tract is a pathway, which is sometimes lined with epithelium, extends directly from the source of the infection to a surface opening, called ______, on the attached gingival surface.
stoma
The _______, by definition, is actually an abnormal communication pathway between two internal organs or from one epithelium-lined surface to another epithelium-lined surface.
fistula
T/F: Histologic studies have found that most sinus tracts are lined with epithelium throughout their entire length.
false (NOT lined)
T/F: The presence of an epithelial lining seem to prevent closure of the tract as long as the source of the problem is properly diagnosed and adequately treated and the endodontic lesion has healed.
false (no effect)
T/F: In general, a periapical infection that has an associated sinus tract is painful, although often there is a history of varying magnitudes of discomfort before sinus tract development.
false (NOT painful)
T/F: Tracing the sinus tract will provide objectivity in diagnosing the location of the problematic tooth.
true
To trace the sinus tract, a size #___ or #___ gutta-percha cone is threaded into the opening of the sinus tract.
25 or 30
To trace the sinus tract properly, the gutta-percha cone should be inserted until …
resistance is felt
What is depicted in the image?
sinus tract tracing
The stomata of intraoral sinus tracts may open in the alveolar mucosa, in the attached gingiva, or through the furcation or gingival crevice. They may exit through either the facial or the lingual tissues depending on the proximity of the root apices to the _______ bone.
cortical
When a narrow defect is present when evaluating a sinus tract, the differential diagnosis must include the opening of ….
a periradicular endodontic lesion, a vertical root fracture, or the presence of a developmental groove on the root surface.
A palpation test is performed by applying firm digital pressure to the mucosa covering the roots and apices. The index finger is used to press the mucosa against the underlying cortical bone. This will detect the presence of periradicular abnormalities or specific areas that produce painful response to digital pressure. A positive response to palpation may indicate what?
an active periradicular inflammatory process
T/F: The palpation test indicates whether the inflammatory process is of endodontic or periodontal origin.
false (does not differentiate)
Pain to percussion does not indicate that the tooth is vital or nonvital but is rather an indication of ___________ (i.e., symptomatic apical periodontitis).
inflammation in the periodontal ligament
This is why it may be difficult for the patient to discriminate the location of dental pain in the earlier stages of pathosis, when only the C fibers are stimulated.
many proprioceptors in the PDL space
T/F: The contralateral tooth should first be tested as a control, as should several adjacent teeth that are certain to respond normally.
true
T/F: The tooth crown is tapped vertically and horizontally. The tooth should first be percussed occlusally, and if the patient discerns no difference, the test should be repeated, percussing the buccal and lingual aspects of the teeth.
true
T/F: The percussion test helps disclose the condition of the pulp and indicates the presence of a periradicular inflammation.
false (NOT the pulp)
T/F: Like percussion testing, an increase in tooth mobility is not an indication of pulp vitality.
true
Which test is merely an indication of a compromised periodontal attachment apparatus?
mobility
T/F: Often the mobility reverses to normal after the initiating factors are repaired or eliminated.
true
T/F: Because determining mobility by simple finger pressure can be visually subjective, the back ends of two mirror handles should be used, one on the buccal aspect and one on the lingual aspect of the tooth
true
Any mobility that exceeds +___ should be considered abnormal.
1
T/F: Isolated areas of vertical bone loss may be of an endodontic origin, specifically from a nonvital tooth whose infection has extended from the periapex to the gingival sulcus.
true
T/F: For example, a periodontal pocket of endodontic origin may resolve after endodontic treatment, but if the tooth was originally vital with an associated deep periodontal pocket, endodontic treatment will not improve the periodontal condition.
true
A _________ may often cause a localized narrow periodontal pocket that extends deep down the root surface.
vertical root fracture
What is the furcation involvement tell you?
Furcation bone loss can be secondary to periodontal or pulpal disease.
Cold testing is the primary pulp testing method used by many clinicians today. It is especially useful for patients presenting with what materials where no natural tooth surface (or much metal) is accessible.
crowns
What is the most common type of cold testing is used?
refrigerant spray
T/F: Frozen carbon dioxide has also been found to be effective in evaluating the pulpal response in teeth with full coverage crowns for which other tests such as electric pulp testing is not possible.
true
To be most reliable, cold testing should be used in conjunction with what test so that the results from one test will verify the findings of the other test?
an electric pulp tester
If a mature, nontraumatized tooth does not respond to both cold testing and electric pulp testing, then the pulp can be considered _______.
necrotic
T/F: A multirooted tooth, with at least one root containing vital pulp tissue, would respond negative to a cold test and electric pulp test even if one or more of the roots contain necrotic pulp tissue.
false (will RESPOND POSITIVE)
What type of testing is most useful when a patient’s chief complaint is intense dental pain on contact with any hot liquid or food?
Heat testing
When a patient is unable to identify which tooth is sensitive, a ____test is appropriate.
heat
With _____ testing, a delayed response may occur, so waiting 10 seconds between each heat test will allow sufficient time for the onset of symptoms.
heat
T/F: It should be noted that the sensibility of the pulp is determined by the intactness and health of the vascular supply, not by the status of the pulpal nerve fibers.
true
T/F: The response of the pulp to electric testing reflect the histologic health or disease status of the pulp.
false - a response by the pulp to the electric current only denotes that some viable nerve fibers are present in the pulp and are capable of responding.
Studies have shown that _________ results are most accurate when no response is obtained to any amount of electric current. This lack of response has been found most frequently when a necrotic pulp is present.
electric pulp test
What conditions may cause false-positive responses?
Partial pulp necrosis
Patient’s high anxiety
Ineffective tooth isolation
Contact with metal restorations
What conditions may cause false-negative responses?
Calcific obliterations in the root canals
Recently traumatized teeth
Immature apex
Drugs that increase patient’s threshold for pain
Poor contact of pulp tester to tooth
The electric pulp tester will not work unless the probe can be placed in contact with or be bridged to the __________.
natural tooth structure
Definition of sensibility
ability of a test to identify teeth that are diseased
Definition of specificity
ability of a test to identify teeth without disease
What method is used to assess blood flow in microvascular systems.?
Laser Doppler flowmetry (LDF)
The Doppler principle states that the light beam’s frequency will shift when hitting moving red blood cells but will remain unshifted as it passes through static tissue.
Certain ______ injuries will cause inaccuracies in the results of electric and thermal pulp testing. What test should be used instead?
luxation, LDF
Describe how pulse oximetry works
Pulse oximetry measures the amount of light absorbed based on the ratio of oxygenated to deoxygenated hemoglobin in the blood.
How helpful is pulse oximetry in assessing pulp health?
contradicting
The tooth may be sensitive to _____ when the pulpal pathosis has extended into the periodontal ligament space, creating a symptomatic apical periodontitis, or the sensitivity may be present secondary to a crack in the tooth.
biting
If ___________ is present, the tooth will respond with pain to percussion and biting tests regardless of where the pressure is applied to the coronal part of the tooth.
periradicular periodontitis
T/F: A cracked tooth or fractured cusp will typically elicit pain only when the bite or percussion test is applied in a certain direction to one cusp or section of the tooth.
true
The Tooth Slooth (Professional Results, Laguna Niguel, CA) and FracFinder (Hu-Friedy, Oakbrook, IL) are just two of the commercially available devices used for what type of test?
bite
A common finding with a _______ or a ________ is the frequent presence of pain upon release of biting pressure.
fractured cusp or cracked tooth
This method is used only when all other test methods are deemed impossible or the results of the other tests are inconclusive. An example of a situation in which this method can be used is when the tooth suspected of having pulpal disease has a full coverage crown.
test cavity - a small class I cavity preparation is made through the occlusal surface of the crown. The patient is not anesthetized while this procedure is performed, and the patient is asked to respond if any painful sensation is felt during the drilling procedure.
T/F: The test cavity method elicits a sensation signifies that the pulp is healthy. If the patient fails to feel any sensation when the bur reaches the dentin, this is a good indication that the pulp is necrotic and root canal therapy is indicated.
false - This sensation signifies only that there is some viable nerve tissue remaining in the pulp, not that the pulp is totally healthy.
What dye is used to see if there is a presence of a crack in the surface of a tooth?
methylene blue dye
When symptoms are not localized or referred, the diagnosis may be challenging. Sometimes the patient may not even be able to specify whether the symptoms are emanating from the maxillary or mandibular arch. In these instances, when pulp testing is inconclusive, _________ may be helpful.
selective anesthesia
If the patient cannot determine which arch the pain is coming from, then the clinician should first selectively anesthetize which arch?
maxillary
T/F: It should be understood that periodontal ligament injections may anesthetize an adjacent tooth and thus are more useful for identifying the arch rather than the specific tooth.
true
By virtue of “casting a shadow,” the anatomic features that are closest to the film (or sensor) will move the _____ when there is a change in the horizontal or vertical angulation of the radiation source.
least
On occasion no radiographic change can be seen at all, even in the presence of a disease process in the alveolar bone. This is mainly due to the fact that the disease process did not reach the …
alveolar bone
Two-dimensional dental radiography has two basic shortcomings:
the lack of early detection of pathosis in the cancellous bone, because of the density of the cortical plates, and the influence of the superimposition of anatomic structures.
T/F: Radiographic changes from bone loss will not be detected if the loss is only in cancellous bone.
true
The radiographic appearance of endodontic pathosis is correlated with the relationship of what two things?
the periapex of the tooth and its juxtaposition to the cortical-cancellous bone junction
Compare the radiographic appearnce of endodontic pathosis between the anterior and premolars and the molars?
The apices of most anterior and premolar teeth are located close to the cortical-cancellous bone junction. Therefore, periapical pathosis from these teeth is exhibited sooner on the radiograph. By comparison, the distal roots of mandibular first molars and both roots of mandibular second molars are generally positioned more centrally within the cancellous bone, as are maxillary molars, especially the palatal roots. Periapical lesions from these roots must expand more before they reach the cortical-cancellous bone junction and are recognized as radiographic pathosis. For these reasons, it is important not to exclude the possibility of pulpal pathosis in situations in which there are no radiographic changes.
____________ has an advantage over conventional film in that the image can be enhanced and colorized—a useful tool for patient education.
Digital radiography
For CBCT, the image is instead captured as a series of three-dimensional pixels, known as ____.
voxels
Studies show that which type of imaging is much more predictable and efficient in demonstrating anatomic landmarks, bone density, bone loss, periapical lesions, root fractures, root perforations, and root resorptions?
CBCT
T/F: The accuracy of CBCT helps us replace conventional radiographs in diagnosing endodontic pathosis.
false - CBCT should not be seen as a replacement for conventional dental radiography, but rather as a diagnostic adjunct. The advantage of conventional dental radiography is that it can visualize most of the structures in one image. CBCT can show great detail in many planes of vision but can also leave out important details if the “slice” is not in the area of existing pathosis.
T/F: MRI has the same usefulness in diagnostic tools as CBCTs.
false - Magnetic resonance imaging (MRI) has also been suggested for dental diagnosis. It may offer simultaneous three-dimensional hard- and soft-tissue imaging of teeth without ionizing radiation. The use of MRI in endodontics is still limited.
Cracks in teeth can be divided into three what three basic categories?
craze lines, fractures (cracks), and split teeth/roots
