Diagnosis in Endo Flashcards
What is the process of diagnosis
- Why Is the patient seeking advice, why have they come to the dentist
- History and symptoms prompting visit
- Objective clinical tests which allow us to arrive to the reason for the problem is
- Correlation of objective findings and subjective details to create a differential diagnosis
Formulation of definitive diagnosis
What are the elements required to formulate an accurate diagnosis
○ Questioning ○ Listening ○ Testing ○ Interpreting ○ Answering 'why?' ○ Not just gathering data ○ Data interpretation ○ Data processing ○ Questionable versus significant ○ Active dialogue
For endodontics diagnosis what do we require
○ Patient history ○ Clinical (endodontic) examination ○ Radiographs ○ Special investigations Clinical reasoning
What is the present complaint
- What is there reason for attendance
- This serves as a clue for diagnosis
- Take the history of the presenting complaint
Document using the patient’s own words
What is the history of presenting complaint
- Chronology of events leading to presenting complaint
- Past and present symptoms
○ Has it been sore in the past
○ Is it sore now? - Procedures or trauma
Clinician lead conversation to produce a clear and concise narrative
- Past and present symptoms
What are the two types of pain
odnotogenic
non odontogenic
What is the response of the trigeminal branches to thermal, mechanical or chemical stimuli
pain
What are the fibres responsible for dental pain
a delta
c
What are a delta fibres responsible for
○ Sharp pricking sensation
Early shooting pain
What are c fibres responsible for
○ Dull, aching or burning
Late dull pain
What is an endo emergency
- Pain or swelling caused by carious stages of inflammation or infection of the pulpal and/or periapical tissues
- Sometimes patients think if the pulp is taken out they will no longer suffer symptoms but this is not true as the PDL and alveolar bone can also suffer from inflammation
What is a pain history
- Site
- Onset
- Character
- Radiation
- Association
- Time course
- Exacerbating/relieving factors
Severity
What are questions about pain
- Where is the pain
- What does the pain feel like
- How bad is the pain
- How long is the pain for
- Does anything take the pain away
- What makes the pain worse
- Does the pain keep you away at night
- Does the pain come on randomly/spontaneously
- Have you had this before
- Have you had any dental work recently
- Have you ever suffered any trauma
What is referred pain
- Perception of pain in one part of the body distant from the source of pain
- It is difficult to discriminate location of pulpal pain
- Referred pain usually provoked by intense stimulation of C-fibres leading to intense slow, dull pain
It always radiates to the ipsilateral side
Where do anterior teeth refer pain
- Anterior teeth seldom refer pain to other teeth or opposite arch
Where do posterior teeth refer pain
Posterior teeth often refer to opposite arch or periauricular area but seldom to anterior teeth
Where do mandibular posterior teeth refer pain
Mandibular posterior teeth refer pain to periauricular area more often than maxillary
Why is medical history important
- Medical conditions and medications that impact on management
Medical conditions that may have oral manifestations or mimic dental pathosis
What are non-odontogenic causes of lymph node invovlemt
TB
lymphoma
What are non-odontogenic causes of paraesthesia
Leukaemia
Anaemia
What are non-odontogenic causes of bone pain
Sickle cell anaemia
What are non odontogenic causes of tooth mobility
Multiple myeloma
What are non odontigenic causes of pain
○ MS
○ Acute maxillary sinusitis
Trigeminal neuralgia
What is clinical reasoning
higher order thinking in which the health care provider, guided by the best evidence or theory observes and relates concepts and phenomena to develop an understanding of their significance
What does clinical reasoning require
use of a patient’s history, physical signs, symptoms, lab data and radiological images to arrive at diagnosis and formulate a plan of treatment
What does an Endodontics exam consist of
- Extraoral exam
- Intraoral exam
- Soft tissue exam
- Intraoral swelling
- Sinus tracts
- Palpation
- Percussion
- Mobility
Periodontal exam
What are the different types of sensibility testing
- Consists of pulp tests ○ Thermal ○ Electric ○ Laser doppler flowmetry Pulse oximetry
What is sensibility testing
est sensibility NOT vitality
- Subjective - Contra-lateral teeth should be tested - Assumption that the nerve fibres in the pulp correlates to intact blood supply is not appropriate
Why are multi rooted teeth problematic for sensibility testing
Problems with multirooted teeth is that when one root canal could be necrotic, the other could be normal and respond normally to testing
What is cold sensibility testing
Relies on hydrodynamic forces
What is used for cold sensibility tests
frozen CO2 (-78 degrees)
ethyl chlroide
ice is unreliable
What is the procedure for cold sensibility tests
○ Refrigerate spray
○ Dry and isolate
Put close to pulp horn
What are sensibility heat tests
- Have to be careful as too much heat may cause irreversible pulpitis
- Hot gutta percha can be used, use vaseline
Can occasionally get patient to rinse with warm water with a dental dam but not used very much
- Hot gutta percha can be used, use vaseline
What is EPT
- Electric current used to stimulate sensory nerves
- Primary A-delta fast conducting fibres
- Unmyelinated C-fibres may or may not respond
What is the procedure for EPT
○ Dry teeth and isolate ○ Probe place on incisal edge or cusp tip (pulp horn proximity) ○ Conducting medium used ○ Circuit completed Current slowly increases until response
How reliable is EPT
- EPT gives no indication of reversibility of inflammation
- EPT gives no correlation between threshold and pulp condition
- Negative response is a reliable indicator
- EPT is unreliable on open apices (young patients)
What are other special tests
bite test (fracture finder or tooth sleuth) test cavity (drill without LA and look for response) staining and transillumination selective anaesthesia (anaesthetise suspected tooth and see if pain remains)
Are radiographs useful
- Without a proper history and clinical exam and testing a radiograph alone may lead to misinterpretation of normality and pathosis
- Two pre-op radiographs from different angulations can be good for multirooted teeth
- Subjective nature of the radiographic appearance of endodontic pathosis
- CBCT can be useful
What is sinus tract tracing
- Put GP right through a sinus tract until it stops
Can take a radiograph and see the particular route of it and give you some information on the source of infection
When looking at radiograph and assessing what are the 3 stages
○ Crown § Caries § Fracture ○ Middle of tooth § Pulpal diagnosis ○ Bottom of tooth § Apex, bone, soft tissue Periradicular
What are the pulpal diagnoses
- Normal pulp
- Reversible pulpitis
- Symptomatic irreversible pulpitis
- Asymptomatic irreversible pulpitis
- Pulp necrosis
- Previously treated
- Previously initiated therapy
What is a normal pulp
- Symptom free and normally responsive to pulp testing
- Pulp may not be histologically normal
How do you test a normal pulp
- ‘clinically’ normal pulp results in a mild or transient response to thermal cold testing, lasting no more than one to two seconds after stimulus is removed
- Compare the tooth in question with adjacent and contralateral teeth
Test other teeth first so patient is familiar with experience of a normal response to cold
- Compare the tooth in question with adjacent and contralateral teeth
What is reversible pulpitis
- Inflammation should resolve following management
- Discomfort is experienced on application of stimulus
- Happens from exposed dentine (dentinal sensitivity), caries or deep restorations
- No significant radiographic change in periapical region
- Pain experienced is not spontaneous
- Follow up required to determine if pulp has returned to normal
- Although dentinal sensitivity is not an inflammatory process, all of the symptoms of it mimic reversible pulpitis
Sometimes best to do a non invasive thing first to see if that resolves it
What is symptomatic irreversible pulpitis
- Vital inflamed pulp is incapable of healing
RCT indicated
What are the characteristics symptomatic irreversible pulpitis
Sharp pain upon thermal stimuli
Lingering pain (often 30 seconds or longer after stimulus removal)
Spontaneity (unprovoked pain) and referred pain
May get worse by posture
OTC analgesics not helpful
How may symptomatic irreversible pulpitis pain be accentuated
by postural changes e.g lying down or bending over
What are common etiologies for symptomatic irreversible pulpitis
○ Deep caries
○ Extensive restorations
○ Fractures exposing pulp tissues
Why are teeth with symptomatic irreversible pulpitis difficult to diagnose
- Teeth with symptomatic irreversible pulpitis may be difficult to diagnose because the inflammation has not yet reached the periapical tissues, thus resulting in no pain or discomfort to percussion
- Dental history and thermal testing are the primary tools for assessing pulpal status
What is asymptomatic irreversible pulpitis
- Vital inflamed pulp is incapable of healing and that RCT is indicated
- No clinical symptoms and usually respond normally to thermal testing but may have had trauma or deep caries that would likely result in exposure following removal
- It is most likely a category of exclusion
What is pulp necrosis
Diagnostic indicating death of the dental pulp, necessitating root canal treatment
Non responsive to pulp testing and is asymptomatic
Does not by itself cause apical periodontitis unless the canal is infected
What is previously treated pulp
- Clinically diagnostic category indicating that the tooth has been endodontically treated
- Canals are obturated with various filling materials other than intracanal medicaments
The tooth typically does not respond to thermal or electric pulp testing
- Canals are obturated with various filling materials other than intracanal medicaments
What is previously initiated pulp
- Clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy such as pulpotomy or pulpectomy
Depending on the level of therapy, the tooth may or may not respond to pulp testing modalities
What are the apical diagnoses
- Normal apical tissues
- Symptomatic apical periodontitis
- Asymptomatic apical periodontitis
- Chronic apical abscess
- Acute apical abscess
Condensing osteitis
What is norma apical tissue
- Not sensitive to percussion or palpation testing and radiographically, the lamina dura
- Surrounding the root is intact and the periodontal ligament space is uniform
Comparative testing for percussion and palpation should always begin with normal teeth as a baseline for the patient
- Surrounding the root is intact and the periodontal ligament space is uniform
What is symptomatic apical periodontitis
- Represents inflammation, usually of the apical periodontium
- Painful response to biting and/or percussion or palpation
- May or may not be accompanied by radiographic changes (i.e depending upon the stage of the disease there may be normal width of the periodontal ligament or there may be a periapical radiolucency)
- Severe pain to percussion and/or palpation is highly indicative of a degenerating pulp and root canal treatment is needed
What is asymptotic apical periodontitis
- Inflammation and destruction of the apical periodontium that is of pulpal origin
Appears as an apical radiolucency and does not present clinical symptoms (no pain on percussion or palpation)
What is chronic apical abscess
Inflammatory reaction to pulpal infection and necrosis
Radiographically, signs of osseus destruction such as a radiolucency
Sinus tract tracing is possible
What are the characteristics of chronic apical abscess
Gradual onset
No discomfort
Intermittent discharge of pus through an associated sinus tract
What are the characteristics of acute apical abscess
Rapid onset
Spontaneous pain
Extreme tenderness of the tooth to pressure
Pus formation and swelling of associated tissues
What is acute apical abscess
- Inflammatory reaction to pulpal infection and necrosis
- May be no radiographic signs of destruction
- Patient often experiences malaise, fever and lymphadenopathy
- Look out for eye closing or threatened airway as this is dangerous
What is condensing osteitis
Diffuse radiopaque lesion representing a localized bony reaction to a low grade inflammatory stimulus usually seen at the apex of the toot
What are treatment options
- RCT (for irreversible pulpitis or necrotic pulp then may be good0
- Re RECT
- Extract tooth
- Monitor and don’t intervene
- Surgical intervention
