Diagnosis of pulp and periapical disease and special investigations Flashcards
Diagnosis of endodontic disease
Endodontic diagnosis like jigsaw, cannot be made from single piece of info
Careful history followed by thorough examination should lead to preliminary diagnosis
-in some cases this is inconclusive or give conflicting results –> no definitive diagnosis
Treatment should not be undertaken without diagnosis
-pxs may have to wait and be reassessed at later date
Pattern of diagnosis
Px complaint History of complaint Medical history Dental history Clinical examination Special investigations Diagnosis
Patient complaint
Listen carefully to what px tell you
-often you have good idea of diagnosis before you look in mouth
History of complaint
When did you first notice problem Continuous or intermittent? Are there any initiating or relieving factors? Getting worse or staying same? Where is problem?
History of complaint (specific to pain)
Location Initiating or relieving factors Character Duration Severity Spread/ radiation
Medical history
General medical history
Medical history relevant to complaint
-drug history (analgesics, antibiotics, bisphosphonates)
–>careful extracting pxs taking bisphosphonates, may get necrotic jaw
Dental history
Has any treatment been initiated?
Has any treatment provided given relief from symptoms?
What is time course for treatment provided?
Does px’s reported dental history match with clinical findings?
Examination
Extra-oral -TMJ -Lymph nodes -Any signs of extra-oral pathology? Intra-oral -Soft tissues -Occlusion -Periodontal examination (BPE, 6 point probing chart) -Dental hard tissues
Intra-oral exam soft tissues
General soft tissue exam -tongue -palate -floor of mouth -buccal mucosa/ sulci Specific to tooth -presence of swelling or sinus
If swelling is bony hard
Cyst or tumour
If swelling moves
Acute abscess
Occlusion
Are there any aspects of occlusion relevant to symptoms?
-check for fremitus (tooth movement in occlusion)
-check contacts in ICP
-check first contact in centric relation
-check excursions (lateral and protrusive)
Ideally, contacts should be even, without excessive forces on individual teeth
Occlusion with teeth with acute apical abscess
May become raised occlusally due to build up of p resulting in extreme tenderness on biting and high occlusal contact
Periodontal examination
General periodontal examination
-BPE
-6 point probing if indicated if codes 3 or 4
Specific periodontal examination
-walk probe around entire gingival margin of tooth in question
-assess level of attachment loss, if present
-check for isolated deep pocket - highly indicative of vertical root fracture
-mobility
Vertical root fracture
J shaped lesion
Hopeless prognosis - tooth requires extraction
Mobility
Mobility of tooth may indicate:
Periodontal bone loss
-loss of periodontal support may indicate generally poor prognosis for tooth
Presence of apical bone loss resulting in reduced bone support
-if periodontal support satisfactory, mobility should improve following resolution of apical pathology
Miller’s grading system
Mobility Grades 1, 2, 3 1: <1mm 2: in between 3: >2mm
Dental hard tissues
Full dental examination -caries -restorations (failing, recently placed) Specific tooth examination -as above and check for tooth discolouration
Tooth discolouration
Can be split into 2 groups (from endodontic aetiology)
- yellow/ cream discolouration: due to deposition of tertiary dentine resulting in thicker dentine tissue and reduced light transmission (tooth may be vital or non-vital)
- grey/ black discolouration: due to pulpal blood products staining dentine (tooth generally non-vital)
Special investigations
Pulp tests
Periapical tests
Additional tests
Radiography
Pulp test definitions
Sensibility test
-tests ability to respond to stimulus
-assessment of pulp’s nerve supply
Vitality testing
-test whether pulp is vital i.e. has functional blood supply
Note: pulp tissue may have adequate vascular supply, but is not necessarily innervated
Pulp tests examples
Sensibility tests: cold, heat, electric
Vitality tests:
-pulse-oximetry
-laser Doppler flowmetry
Do nerves die with destruction of pulp tissue?
Nerve fibres can maintain structural identity even in advanced stages of pulpitis where there is considerable destruction of other components of pulp tissue
-may give +ve response to pulp testing
Aδ fibres
Pain, temperature, touch
C dorsal root
Pain
Character of pain
In dental pain the sharp, rapid pain is probably reaction of Aδ fibres, which extend into dentine, to external stimuli
Achy, dull pain probably associated with deeper slow-reacting and high threshold unmyelinated C-fibres
-indicative of pulpal inflammation
Sensibility tests: cold
Ethyl chloride Ice -least cold Frozen CO2 Propane/ butane spray -coldest
Sensibility test: heat
Heated wax
Heated gutta percha
Hot liquid
Ethyl chloride test
- explain procedure to px
- spray ethyl chloride onto cotton wool pellet and wait few s for ice crystal to form
- ideally isolate tooth in qu
- test adjacent tooth, buccal and palatal
- wait at least 30s
- test tooth in qu buccal and palatal
- if no response, wait one min, then test again
Cold thermal test
-theoretically, only sensation from tooth can be pain
-sensation may be mild or severe pain
-intensity of sensation gives indication of level of pulpal inflammation
-+ve response likely to indicate functioning nerve tissue but false +ves possible
–ve response likely to indicate no functioning nerve tissue, false -ve possible
First test will give best and most accurate response
General principles of cold testing
Pain can refer from one arch to other
Never crosses midline
Pain will always start in arch where source of problem is
Heat test
Generally used much less commonly than cold testing Possible methods -heated wax -heated gutta percha -hot liquid
Electric pulp test
Tests function of nerve tissue in tooth
Stimulates nerves directly
Electric pulp test method
Explain procedure to px
Identify tooth in qu
Use toothpaste to form good contact with tooth
Test adjacent tooth, buccal surface
Wait at least 30s
Test tooth in qu buccal surface
If no response, wait one min, then test again
Factors affecting reliability of sensibility testing
Varying thickness of enamel/ dentine
Restorations, notably crowns
Teeth with open apices
Px response factors
Reproducibility of sensibility tests
Pxs respond differently to pulp tests on different days, and at different hours of same day
Reproducibility of pulp testing area of concern and may relate to variable state of mind of px as well as lack of intrinsic accuracy
Sensitivity (true positive)
Measures proportion of actual +ves which are correctly identified as such
Specificity (true negative)
Measures proportion of -ves which are correctly identified as such
Pulse-oximetry
Passes wavelengths of light to photo sensor to detect pulsing arterial blood
Equipment expensive
Not proven to be as reliable as current, cheap methods of sensibility testing
Laser doppler flowmetry
Light transmitted through pulp
If blood flow present the light will be scattered, which is detected by sensor
Equipment expensive
Not proven to be as reliable as current, cheap methods of sensibility testing
Perapical tests
Percussion
Palpation
Tooth slooth
Percussion/ palpation
Not true vitality tests
Indicates presence of inflammation in periodontium
TTP more frequent where partial or total necrosis present
Palpation
Palpate over apices tocheck for apical inflammation and pus production
Tooth slooth
Allows p testing of individual cusps
Pain on biting usually indication of periapical inflammation
Pain on release of p usually indication of crack
Test for cracks
Tongue spatula if you can’t afford tooth slooth
Additional tests
Transillumination
Selective anaesthesia
Test cavity
Transillumination
Direct light through tooth to detect pathology, especially crack and fractures which cannot be seen under dental light
Selective anaesthesia
When having difficulty locating source of pain (e.g. upper or lower), anaesthetise selected teeth to find source
Also useful when ruling out non-peripheral source for pain
Test cavity
Last resort!
Begin access cavity prep
No local anaesthesia
If px feels sensation then tooth is vital
If no sensation, proceed with endodontic treatment
When to take x-rays
X-rays taken after you have arrived at provisional diagnosis
-they help to confirm diagnosis
Radiographs
Bitewings or periapicals
OPT and occlusal views less commonly used for pulp and periapical disease diagnosis
Bitewings
Refer to clinical guidelines regarding frequency of bitewings
Use bitewings to screen for caries/ pathology at appropriate intervals
Also use to confirm suspected pathology following an examination
Periapicals
Take as indicated following clinical examination
Used to detect apical pathology, periodontal bone loss, root fractures etc.
Diagnostic warning signs
Pulp chamber constriction -inflamed pulp Pulp stones possibly indicate -previous trauma -occlusal parafunction
Diagnostic aids for radiographs
If sinus present insert gutta percha point into sinus tract
-the point will appear on radiograph and ‘point’ to source of infection
CBCT?
Cone beam CT scans
Can be used in specific circumstances to aid diagnosis
3D image of teeth in qu
Extra radiation dose to px, must justify
