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BDS3 CLINICAL Endodontics > Diagnosis in Endo > Flashcards

Diagnosis in Endo Flashcards

1
Q

What is the process of diagnosis

A
  1. Why Is the patient seeking advice, why have they come to the dentist
    1. History and symptoms prompting visit
    2. Objective clinical tests which allow us to arrive to the reason for the problem is
    3. Correlation of objective findings and subjective details to create a differential diagnosis
      Formulation of definitive diagnosis
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2
Q

What are the elements required to formulate an accurate diagnosis

A 
○ Questioning
○ Listening
○ Testing
○ Interpreting
○ Answering 'why?'
○ Not just gathering data
○ Data interpretation
○ Data processing
○ Questionable versus significant
○ Active dialogue
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3
Q

For endodontics diagnosis what do we require

A 
○ Patient history
		○ Clinical (endodontic) examination
		○ Radiographs
		○ Special investigations
Clinical reasoning
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4
Q

What is the present complaint

A
  • 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
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5
Q

What is the history of presenting complaint

A
  • 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
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6
Q

What are the two types of pain

A

odnotogenic

non odontogenic

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7
Q

What is the response of the trigeminal branches to thermal, mechanical or chemical stimuli

A

pain

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8
Q

What are the fibres responsible for dental pain

A

a delta

c

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9
Q

What are a delta fibres responsible for

A

○ Sharp pricking sensation

Early shooting pain

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10
Q

What are c fibres responsible for

A

○ Dull, aching or burning

Late dull pain

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11
Q

What is an endo emergency

A
  • 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
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12
Q

What is a pain history

A
  • Site
    • Onset
    • Character
    • Radiation
    • Association
    • Time course
    • Exacerbating/relieving factors
      Severity
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13
Q

What are questions about pain

A
  • 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
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14
Q

What is referred pain

A
  • 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
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15
Q

Where do anterior teeth refer pain

A
  • Anterior teeth seldom refer pain to other teeth or opposite arch
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16
Q

Where do posterior teeth refer pain

A

Posterior teeth often refer to opposite arch or periauricular area but seldom to anterior teeth

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17
Q

Where do mandibular posterior teeth refer pain

A

Mandibular posterior teeth refer pain to periauricular area more often than maxillary

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18
Q

Why is medical history important

A
  • Medical conditions and medications that impact on management
    Medical conditions that may have oral manifestations or mimic dental pathosis
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19
Q

What are non-odontogenic causes of lymph node invovlemt

A

TB

lymphoma

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20
Q

What are non-odontogenic causes of paraesthesia

A

Leukaemia

Anaemia

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21
Q

What are non-odontogenic causes of bone pain

A

Sickle cell anaemia

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22
Q

What are non odontogenic causes of tooth mobility

A

Multiple myeloma

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23
Q

What are non odontigenic causes of pain

A

○ MS
○ Acute maxillary sinusitis
Trigeminal neuralgia

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24
Q

What is clinical reasoning

A

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

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25
Q

What does clinical reasoning require

A

use of a patient’s history, physical signs, symptoms, lab data and radiological images to arrive at diagnosis and formulate a plan of treatment

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26
Q

What does an Endodontics exam consist of

A
  • Extraoral exam
    • Intraoral exam
    • Soft tissue exam
    • Intraoral swelling
    • Sinus tracts
    • Palpation
    • Percussion
    • Mobility
      Periodontal exam
27
Q

What are the different types of sensibility testing

A 
- Consists of pulp tests
		○ Thermal 
		○ Electric
		○ Laser doppler flowmetry
Pulse oximetry
28
Q

What is sensibility testing

A

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
29
Q

Why are multi rooted teeth problematic for sensibility testing

A

Problems with multirooted teeth is that when one root canal could be necrotic, the other could be normal and respond normally to testing

30
Q

What is cold sensibility testing

A

Relies on hydrodynamic forces

31
Q

What is used for cold sensibility tests

A

frozen CO2 (-78 degrees)
ethyl chlroide
ice is unreliable

32
Q

What is the procedure for cold sensibility tests

A

○ Refrigerate spray
○ Dry and isolate
Put close to pulp horn

33
Q

What are sensibility heat tests

A
  • 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
34
Q

What is EPT

A
  • Electric current used to stimulate sensory nerves
    • Primary A-delta fast conducting fibres
    • Unmyelinated C-fibres may or may not respond
35
Q

What is the procedure for EPT

A 
○ 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
36
Q

How reliable is EPT

A
  • 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)
37
Q

What are other special tests

A 
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)
38
Q

Are radiographs useful

A
  • 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
39
Q

What is sinus tract tracing

A
  • 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

40
Q

When looking at radiograph and assessing what are the 3 stages

A 
○ Crown 
			§ Caries
			§ Fracture 
		○ Middle of tooth 
			§ Pulpal diagnosis
		○ Bottom of tooth 
			§ Apex, bone, soft tissue 
Periradicular
41
Q

What are the pulpal diagnoses

A
  • Normal pulp
    • Reversible pulpitis
    • Symptomatic irreversible pulpitis
    • Asymptomatic irreversible pulpitis
    • Pulp necrosis
    • Previously treated
    • Previously initiated therapy
42
Q

What is a normal pulp

A
  • Symptom free and normally responsive to pulp testing

- Pulp may not be histologically normal

43
Q

How do you test a normal pulp

A
  • ‘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
44
Q

What is reversible pulpitis

A
  • 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
45
Q

What is symptomatic irreversible pulpitis

A
  • Vital inflamed pulp is incapable of healing

RCT indicated

46
Q

What are the characteristics symptomatic irreversible pulpitis

A

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

47
Q

How may symptomatic irreversible pulpitis pain be accentuated

A

by postural changes e.g lying down or bending over

48
Q

What are common etiologies for symptomatic irreversible pulpitis

A

○ Deep caries
○ Extensive restorations
○ Fractures exposing pulp tissues

49
Q

Why are teeth with symptomatic irreversible pulpitis difficult to diagnose

A
  • 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
50
Q

What is asymptomatic irreversible pulpitis

A
  • 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
51
Q

What is pulp necrosis

A

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

52
Q

What is previously treated pulp

A
  • 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
53
Q

What is previously initiated pulp

A
  • 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
54
Q

What are the apical diagnoses

A
  • Normal apical tissues
    • Symptomatic apical periodontitis
    • Asymptomatic apical periodontitis
    • Chronic apical abscess
    • Acute apical abscess
      Condensing osteitis
55
Q

What is norma apical tissue

A
  • 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
56
Q

What is symptomatic apical periodontitis

A
  • 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
57
Q

What is asymptotic apical periodontitis

A
  • 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)
58
Q

What is chronic apical abscess

A

Inflammatory reaction to pulpal infection and necrosis
Radiographically, signs of osseus destruction such as a radiolucency
Sinus tract tracing is possible

59
Q

What are the characteristics of chronic apical abscess

A

Gradual onset
No discomfort
Intermittent discharge of pus through an associated sinus tract

60
Q

What are the characteristics of acute apical abscess

A

Rapid onset
Spontaneous pain
Extreme tenderness of the tooth to pressure
Pus formation and swelling of associated tissues

61
Q

What is acute apical abscess

A
  • 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
62
Q

What is condensing osteitis

A

Diffuse radiopaque lesion representing a localized bony reaction to a low grade inflammatory stimulus usually seen at the apex of the toot

63
Q

What are treatment options

A
  • RCT (for irreversible pulpitis or necrotic pulp then may be good0
    • Re RECT
    • Extract tooth
    • Monitor and don’t intervene
    • Surgical intervention

BDS3 CLINICAL Endodontics (11 decks)

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