Diagnosis in Endodontics

Question 1

Definition of diagnosis

Answer 1

• the identification of the nature of an illness/ other problem by examination of symptoms

Question 2

Process of diagnosis

Answer 2

1. why is pt seeking advice
2. history and symptoms prompting visit
3. objective clinical tests
4. correlation of objective findings and subjective details to create differential diagnosis
5. formulation of definitive diagnosis

Question 3

History of Presenting Complaint

Answer 3

• chronology of events leading to PC
• Past and present symptoms
• procedures of trauma
• clinician led conversation to produce clear and concise narrative

Question 4

Clinical Notes

Answer 4

Question 5

Types of Pain

Answer 5

• odontogenic
• non-odontogenic

Question 6

Trigeminal nerve branches

Answer 6

• opthalmic
• maxillary
• mandibular
• primarily transmit pain in response to thermal, mechanical/ chemical stimuli

Question 7

What fibres are involved in dental pain?

Answer 7

A -Delta fibres and C fibres

Question 8

A delta fibres

Answer 8

• sharp pricking sensation
• early shooting pain

Question 9

C fibres

Answer 9

• dull aching burning
• late dull pain

Question 10

Pain history

Answer 10

S- site
O- onset
C- character
R- radiation
A- associated symptoms
T- time course
E- exacerbating/ relieving factors
S- severity

Question 11

Questions to ask regarding pain

Answer 11

• where is the pain?
• what does it feel like?
• how bad is the pain?
• how long is it there for?
• does anything take the pain away?
• what makes it worse?
• does it keep you awake at night?
• does the pain come on randomly/ spontaneously?
• have you had this before?
• have you had any dental work recently?
• have you suffered any trauma?

Question 12

What is referred pain?

Answer 12

• perception of pain in one part of body distant from source of pain
• difficult to discriminate location of pulpal pain
• provoked by intense stimulation of C fibres leading to intense slow, dull pain
• radiates to ipsilateral side
• anterior teeth seldom have referred pain
• posterior teeth refer to opp arch
• mandibular posterior to periauricular area more often than maxillary

Question 13

Pulp test - sensibility and vitality

Answer 13

• thermal
• electric
• laser doppler flowmetry
• pulse oximetry

Question 14

About sensibility testing

Answer 14

• not vitality
• subjective
• compare with contra- lateral teeth
• problems with multi- rooted teeth

Question 15

Cold sensibility

Answer 15

• hydrodynamic forces
• cold/hot tests
• frozen CO2 (-78 degree celcius)
• ice less reliable
• ethyl chloride
• dry and isolate first

Question 16

How to perform heat test?

Answer 16

• too much heat may cause irreversible pulpitis
• Hot gutta percha
• hot water and dental dam

Question 17

Electric pulp test

Answer 17

• used to simulate sensory nerves
• A delta which is fast conducting fibres
• unmyelinated c fibres may not respond
• dry teeth and isolate
• probe place on oncisal edge or cusp tip near pulp horns
• use toothpaste as conducting medium

Question 18

What about EPT?

Answer 18

• no indication of reversibility of inflammation
• no correlation between threshold and pulp condition
• negative response reliable indicator
• EPT of teeth with open apices unreliable

Question 19

Other special test

Answer 19

• bite test
• test cavity
• staining and trans-illumination
• selective anesthesia

Question 20

Pulpal diagnosis

Answer 20

• normal pulp
• reversible pulpitis
• symptomatic irreversible pulpitis
• asymptomatic irreversible pulpitis
• pulp necrosis
• previously treated
• previously initiated therapy

Question 21

Normal pulp

Answer 21

• symptom free
• responsive to pulp testing
• mild response to thermal cold testing
• response lasting no more than one/ two seconds after stimulus is removed
• compare with other teeth first so that pt is familiar with experience of a normal response to cold

Question 22

Reversible pulpitis

Answer 22

• inflammation should resolve following appropriate management of aetiology
• discomfort is experienced when stimulus applied only lasting a few seconds
• due to exposed dentine, caries/ deep restorations
• no significant radiographic changes in periapical region
• follow up required to ensure its resolved

Question 23

SIP

Answer 23

• vital inflamed pulp incapable of healing
• RCT is indicated
• sharp pain upon thermla stimulus
• lingering pain often 30s or longer after stimulus removed
• spontaneous pain
• referred pain
• may be influenced by change of posture, ie: lying down/ bending over
• due to deep caries, extensive restorations, fracture exposing pulpal tissues
• may be difficult to diagnose as it has not reach periapical tissues and will not respond to percussion
• DH and thermal testing are vital for assessing pulpal status

Question 24

Asymptomatic irreversible pulpitis

Answer 24

• vital inflamed pulp incapable of healing
• no clinical symptoms
• responds normal to thermal testing
• may have had trauma/ deep caries

Question 25

Pulp necrosis

Answer 25

• death of dental pulp
• non responsive to pulp testing
• asymptomatic
• some teeth may be non- responsive to pulp testing because of calcification, recent history of trauma/ tooth not responding

Question 26

Previously treated

Answer 26

• canals are obturated with various filling materials
• tooth typically does not respond to thermal/ electric pulp testing

Question 27

Previously initiated

Answer 27

• has been treated with pulpotomy/ pulpectomy
• depends on level of therapy, tooth may/ may not respond to pulp testing

Question 28

Apical diagnoses

Answer 28

• normal apical tissues
• symptomatic apical periodontitis
• asymp apical periodontitis
• chronic apical abscess
• acute apical abscess
• condensing osteitis

Question 29

Normal apical tissues

Answer 29

• not sensitive to percussion/ palpation testing
• lamina dura surrounding tooth is intact
• PDL is uniform

Question 30

Symp Apical periodontitis

Answer 30

• inflammation, usually apical periodontium
• painful response to biting/ percussion/ palpation
• may/ may not be accompanied by radiographic changes
• severe pain to percussion/ palpation

Question 31

Asymp apical periodontitis

Answer 31

• inflammation and destruction of apical periodontium that is of pulpal origin
• appears as apical radiolucency and does not present clinical symptoms
• no pain on precussion/ palpation

Question 32

Chronic apical abscess

Answer 32

• inflammatory reaction to pulpal infection and necrosis
• gradual onset
• little to no discomfort
• intermittent discharge of pus through sinus tract
• signs of osseous destruction, such as radiolucency
• sinus tract tracing possible

Question 33

Acute apical abscess

Answer 33

• inflammatory reaction to pulpal infection and necrosis
• rapid onset
• spontaneous pain
• extreme tenderness of tooth to pressure
• pus formation
• swelling of associated tissues
• no radiographic signs of destruction
• often experience malaise, fever and lympadenopathy
• swelling involved

Question 34

Condensing Osteitis

Answer 34

• diffuse radiopaque lesion representing localised bony reaction to low grade inflammatory stimulus
• often seen at apex of tooth

Question 35

Tx options

Answer 35

• RCT
• Re-RCT
• extract tooth
• monitor/ dont intervene
• surgical intervention