Diagnosis in Endodontics Flashcards
What is main aim of dentistry?
prevention
relieve suffering
cure disease
all based on knowledge of clinical pathology
What is the process of a diagnosis?
CO
HPC - symptoms that prompt visit
Objective clinical tests
Differential diagnosis
Definitive diagnosis
Tx options
How do we take a pt history?
CO HPC PMH PDH FH SH
CO - is in pts own words as to why the are here - this gives us clues and then we carry out diagnostic tests
HPC - events that have led to complaint (SOCRATES - site, consent, character, radiation, associated symptoms, time, exacerbating factors, severity)
What do we do following patient history?
Clinical and Endodontics exam
then we can do SIs - radiographs, sensibility testing
What do we assess in E/O?
TMJ
lymph nodes
MOM
Swelling
asymmetry
What do we check during Endodontics exams?
Buccal soft tissue
Palatal or lingual mucosa
colour
palpation
restorations
TTP
sinus
EPT
ethyl chloride
radiographs
Dx
What can pain be?
Odontogenic or non odontogenic
What can pain be transferred via?
trigeminal nerve
opthalmic
maxillary
mandibular
What do branches of CNV primarily transmit pain in response to?
thermal mechanical or chemical stimuli
What types of pain do A delta fibres transmit?
sharp, shooting pain
What do C fibres transmit?
dull aching pain, late pain
What is pain?
Unpleasant sensory experience causes by intense or damaging stimuli
What is agony?
Acute physical or mental pain and is suffering or struggle that precede death
What are some good qs to ask pt about the pain?
Where is the pain?
What does it feel like to u? - sharp? dull? throbbing? aching? constant?
how bad is it - scale of 1-10 with 10 being worst pain you have felt
how long does the pain last?
do analgesics help?
does anything take pain away?
does it keep you awake at night?
have u had this before?
any trauma?
any previous dental work?
What is being awake at night a sign of?
Irreversible pulpits - nothing appears to be managing the pain
What is referred pain?
perception of pain in one part of the body distant from the source of pain and is due to how we form in the womb
What is referred pain provoked by?
C fibres - leads to intense dull slow pain
Where does referred pain radiate to?
Ipsilateral side
Do anterior teeth refer pain?
No its very rare
Do posterior teeth refer pain?
yes often to opposite arch but not anterior teeth
What is an Endodontics emergency?
This is when there is pain or swelling which is caused by various stages of inflammation or infection of the plural and or periodical tissues
What is involved in the Endodontics exam?
EO exam
IO exam - swellings, lumps, bumps, abscesses, abnormalities
soft tissue exam
hard tissue exam - restorations, caries
IO swellings
Sinus tracts
palpation
percussion
mobility
perio exam
What is Ludwig’s angina?
Ludwig’s angina is a rare skin infection that occurs on the floor of the mouth, underneath the tongue. This bacterial infection often occurs after a tooth abscess, which is a collection of pus in the center of a tooth. It can also follow other mouth infections or injuries.
rapidly and frequently fatal progressive gangrenous cellulitis and ooedema of the soft tissues of the neck and floor of the mouth
What are the types of sensibility testing?
Thermal
Electric
What is thermal pulp testing?
This is when we use hot or cold stimuli on the tooth
ethyl chloride - placed on cotton ball and directly onto toot to see pts reaction - do they feel cold sensation?
can also use heated GP but less common as can damage pulp and surrounding mucosa
if we use hot GP to test the pulp what should we do?
Use vaseline - to prevent excessive heat causing irreversible pulpitis
What is electric pulp testing?
This is when we apply a current to the tooth to generate an action potential in A delta fibres
it is done by applying a conducting medium to the tooth (toothpaste) and we then put the probe of the ep tester onto the medium and give pt the conducting probe to complete the circuit and tell pt to let go when they feel tingling sensation
What may not respond in electric pulp testing?
Unmyelinated C fibres
What does pulp testing give no indication of?
reversibility or inflammation - it is hard to tell between reversible and irreversible
In EPT readings is there a correlation between reading and pulp condition?
No - just need a positive reading
What are some issues with pulp testing?
They can be misinterpreted by the patient - subjective testing so to try prevent this we test several teeth to see if pt is onboard with the testing
we assume that a nerve fibre means that there is an intact blood supply however this is not the case always
What do EPT and Ethyl chloride test for?
Sensibility not vitality
What can we use to test for tooth fractures?
Tooth sleuth
How does a tooth sleuth work?
wedged tip that rests between the cusps of posterior teeth.
Pt is asked to “bite” on the Tooth Slooth, the plastic wedge pushes the cusps away from each other. When the patient is asked to “release”, or “open”, the plastic wedge releases the force, and the cusps are allowed to rest again.
In a healthy tooth, = no discomfort at all.
Some patients experience pain on “biting”, = inflammation of the tissues supporting the tooth. This can be caused by many disorders that would need other tests to be properly diagnosed.
Other patients may experience a sharp pain on “release”. This pain on “release” is due to a crack that goes into the dentin of a vital tooth. = you have a cracked tooth!
PLACE TOOTH SLEUTH ON EACH CUSP POINTED SIDE DOWN AND HAVE PT BITE THEN RELEASE = CAN IDENTIFY FRACTURED TOOTH
How can we assess for tooth fractures?
tooth sleuth
staining
transillumination
What x-rays must we take for endo?
2 pre-operative x-rays from different angles
What does radiographic report include?
Type of x-ray
Grading - diagnostically acceptable or diagnostically unacceptable
Apical pathology
Bone loss
Crown
Anything else
What are the types of endo diagnoses?
Normal pulp
reversible pulpitis
symptomatic irreversible pulpitis
asymptomatic irreversible pulpitis
Pulpal necrosis
previously rct
previously initiated therapy
What is a normal pulp?
Pulp that is symptoms free and normally responsive to pulp testing
(pos testing to EPT and ethyl chloride - mild or transient response lasting no more then 1/2 seconds after removing stimuli)
What is reversible pulpitis?
This is where the pulp is inflamed however it should resolve after we manage the cause
What is clinical signs of reversible pulpitis?
Discomfort when application fo stimulus in pulp testing
No significant radiographic changes in the PA region and pain is not spontaneous
not being kept awake at night
When is reversible pulpitis likely?
When pt has exposed dentine, caries or deep restorations
How do we manage reversible pulpitis?
non invasive procedure - such as removing caries and filling and then follow up to check on the pulp
What is symptomatic irreversible pulpitis?
This is when the pulp is vital and inflamed and incapable of healing - pt will need a root canal
What are signs of symptomatic irreversible pulpitis?
Sharp pain on thermal stimulus, pain lingers for 30 seconds or longer after, spontaneous pain, referred pain, can’t sleep
What are thermal testing results for SIP?
sharp pain that lingers for 30 seconds or longer after stimulus removal
What is pain like for SIP?
spontaneous pain
keeps pt up at night
analgesics ineffective
referred pain
What is the pain like for RP?
can be managed by analgesics
discomfort when stimulus applied but only lasts a few seconds
What are the causes of SIP?
deep caries, extensive restos, fractures that expose pulp
Why is it difficult to diagnose SIP?
Inflammation hasn’t yet reached periodical tissues yet - tooth is still vital so no pain or discomfort on percussion
What is asymptomatic irreversible pulpitis?
Vital inflamed pulp incapable of healing with no clinical symptoms
What does AIP usually respond to?
thermal testing normally but pt may have deep caries or trauma that would result in pulpal exposure following removal
What Is pulpal necrosis?
This is when the pulp has died - there is pulpal necrosis and no response to pulp sensibility testing - the pulp is liquefied
What happens when we percuss tooth that has pulpal necrosis?
Pain on percussion
What is previously root canal treated teeth?
This is a tooth that has been endodontically treated - the tooth won’t respond to thermal or EPT
What is a tooth that have previously initiated root canal treatment?
This is tooth that has had partial Endodontics treatment carried out - for example may have had pulpotomy or pulpectomy but still needs finished
What are the apical diagnosis?
Normal apical tissues
Symptomatic apical periodontitis
Asymptomatic Apcical periodontitis
Chronic apical abscess
Acute apical abscess
Condensing osteitis
What are normal apical tissues?
This is when apical tissues are not sensitive to percussion or palpation and radiographically the lamina dura intact and PDL space is uniform
What is the lamina dura?
Lamina dura is compact bone that lies adjacent to the periodontal ligament, in the tooth socket. The lamina dura surrounds the tooth socket and provides the attachment surface with which the Sharpey’s fibers of the periodontal ligament perforate.
What is the PDL?
is a group of specialized connective tissue fibers that essentially attach a tooth to the alveolar bone within which it sits. It inserts into root cementum one side and onto alveolar bone on the other.
When doing percussion and palpation tests what should we always do?
carry out comparative testing with normal teeth to act as a baseline
What is symptomatic apical periodontitis?
This is when there is inflammation of the apical periodontium - pt may have pain when biting and can be TTP
What radiographic changes may be seen in SAP?
can have a normal width of PDlL or periapical radiolucency
What can severe pain on percussion or palpation indicate?
Tooth needs RCT as the pulp is degenerating
What is asymptomatic apical periodontitis?
This is when there is inflammation and destruction of apical periodontium however pt has no clinical symptoms BUT APICAL RADIOLUCENCY - no pain or TTP
What does asymptomatic apical periodontitis appear as?
Appears as periapcial radiolucency but often no clinical symptoms (no pain or TTP)
What is a chronic apical abscess?
This is an inflammatory reaction to pulpal infection or necrosis and has a gradual onset with little to no discomfort and intermittent discharge of pus through a sinus tract
What is the onset of chronic apical abscesses like?
Gradual - pt will experience little to no discomfort and there is intermittent discharge of pus through sinus tract
What is an acute apical abscess?
This is an inflammatory reaction to pulpal infection nd necrosis that has rapid onset with spontaneous pain, extreme tenderness, pus formation and swelling
What are symptoms of acute apical abscess?
Rapid onset
spontaneous pain
extreme tenderness
pus
swelling
no radiographic signs but pt often unwell
What is condensing osteitis?
This is a diffuser radiopaque lesion representing a bony reaction to low grade inflammatory stimulus - usually seen at apex of teeth
What are 5 tx options in endo?
- Do nothing/monitor
- RCT
- Re-RCT
- XLa
- surgical intervention
If pt has irreversible puliptis or necrosis what must we do?
RCT or Xla
