Endo Dx Flashcards
normal pulp
a clinical diagnostic category in which the pulp is symptom free and normally responsive to pulp testing
reversible pulpitis
a clincal diagnosis based on subjective and objective findings indicating that the viral inflammation should resolve and the pulp return to normal
symptomatic irreversible pulpitis
a clinical diagnosis based on subjective and objective findings indicating that the viral inflammed pulp is incapable of healing
additional descriptors: lingering thermal pain, spontaneous pain, referred pain
asymptomatic irreversible pulpitis
a clinical diagnosis based on subjective and objective findings indicating that the vira inflamed pulp is incapable of healing
additional descriptors: no clinical symptoms but inflammatino produced by caries, caries excavation, trauma
pulp necrosis
a clinical diagnosis category indicating death of dental pulp
the pulp is usually nonresponsive to pulp testing
previously treated pulp
clinical diagnosis category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials other than intracanal medicaments
normal apical tissues
teeth with normal periradicular tissues that are not sensitive to percussion or palpitation
the lamina dura surroudning the root is intact and the periodontal ligament space is uniform
previously initiaed pulp therapy
a clinical diagnositc category indicating that the tooth has been previously treated by partial endodotic therapy (e.g. pulpotomy, pulpectomy)
sytompactic apical periodontitis
inflammation, ususally of the apical periodontium, producing clincial symptoms including painful response to biting and/or percussion or palpation, it might or might not be associated with an apical radiolucent area
asymptomatic apical periodontitis
inflammmation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area
acute apical abscess
an inflammatory reaction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area and does not produce clincal symptoms
chronic apical abscess
an inflammatory reaction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area and does not produce clinical symptoms
condensing osteitis
diffuse radiopaque lesion representing a localised bony reactino to a low-grade inflammatory stimulus, usually seen at apex of tooth
how to obtain probably diagnosis
compare tooth in Q with adjacent and contralateral tooth
test these first so pt aware of normal response i.e. to cold
examination procedures required to make an endodontic diagnosis
- medical and dental history
- chief complaint (if any)
- clinical testing
- radiographic analysis
- additional tests
medical dental history
past/recent tx, drugs
chief complaint (if any)
how long
symptoms
duration of pain
location
onset
stimuli
relief
referred
medications
SOCRATES
pain history
sight
onset
character
radiation
associated features
time
exacerbating factors
severity
clinical testing
pulp test - cold, EPT, heat
periapical test - percussion, palpation, tooth slooth (biting)
radiographic analysis
new periapical (at least 2)
bitewing
CBCT
possible additional tests for endo dx
transillumination selective anaesthesia test cavity
normal pulp characteristics
symptom free
may not be histologically normal but is clinically normal
- mild or transient response to thermal cold testing
- lasting no more than 1-2 secnds after stimulus removed
reversible pulpitis characteristics
- Discomfort experience when stimulus applied, goes away in couple of seconds
- Aetiologies: exposed dentine, caries, deep restorations
- No significant radiographic changes in periapical region
- Pain not spontaneous
- Manage aetiology, then further evaluate to determine if reversible pulpitis has returned to normal
- Dentine sensitivity mimics these symptoms but not an inflammatory process
symptomatic irreversible pulpitis
- Sharp pain on thermal stimulus
- Lingering pain (30 secs +)
- Spontaneity (unprovoked) pain
- Referred pain
- Can be accentuated by postural changes e.g. lying down, bending
- Over the counter analgesics typically ineffective
- Aetiologies: deep caries, extensive restorations, fractures exposing the pulpal tissues
- Difficult to diagnose as inflammation not yet reach the periapical tissues, thus no pain/discomfort on percussion
- Dental history and thermal testing needed
asymptomatic irreversible pulpitis
- RCT needed
- respond normally to thermal testing
- can have trauma or deep caries that will be exposed following removal
pulp necrosis characteristics
- Death of dental pulp, needing RCT
- No responsive to pulp testing and is asymptomatic (due to calcification, recent trauma or simply tooth not responding)
- Need to have comparative tests – e.g. pt not respond to thermal test on any tooth
- Normal teeth = baseline for pt
- Doesn’t cause apical periodontitis by itself (pain on percussion or radiographic evidence of osseous breakdown) unless canal infected
previously treated pulp characteristics
does not respond to thermal or EPT
previously initiated therapy pulp characteristics
depending on level of therapy the tooth may or may not respond to pulp tests
normal apical tissues characteristics
not sensitive to percussion/palpation test
radiographically - lamina dura intact, PDL uniform
symptomatic apical periodontitis characteristics
Inflammation (usually apically periodontium)
Clinical symptoms: pain to biting, percussion, palpitation
Radiographic changes potentially
- Depending on stage of disease
- Normal with of PDL, or periradicular radiolucency
Degenerative pulp, RCT needed
asymptomatic apical periodontitis
- Inflammation and destruction of apical periodontium and is of pulpal origin
- Apical radiolucency
- No clinical symptoms
chronic apical abscess symptoms
- inflammatory reaction to pulpal infection and necrosis characterised by gradual onset, little or no discomfort and an intermittent discharge of pus
- Typically signs of osseous destruction and radiolucency
- ID source of draining sinus with GP cone through stoma or opening until it stops, take radiograph
acute apical abscess characteristics
- Inflammatory reaction to pulpal infection and necrosis characterised by rapid onset, pain and tenderness of tooth to pressure, pus and swelling of tissues
- Maybe no radiographic signs of destruction
- Pt often has malaise, fever and lymphadenopathy
condensing osteitis characteristics
diffuse radiopaque lesion representing a localised bony reaction to a low-grade inflammatory stimulus seen at the apex of the tooth
diagnosis
identification of a nature of an illness or other problem by examination of symptoms
process of diagnosis (5)
- why is the pt seeking advice
- history and symptoms prompting visit
- objective findings and subjective details to create differential diagnosis
- formulation of defintive diagnosis
art and science of dx
- Questioning
- Listening
- Testing
- Interpreting
- Answering “Why?”
- Not just gathering data
- Data interpretation
- Data processing
- Questionable versus Significant
- Active dialogue
–> accurate diagnosis and successful Tx plan
endo dx requires
- Patient history
- Clinical (endodontic) examination
- Radiographs
- Special investigations
- Clinical reasoning!
Diagnoses then treatment.
presenting complaint
- reason for attendance > test results
- Serves as clue to diagnosis
- History of presenting complaint
- Document using patient’s own words
history of presenting complaint
- Chronology of events leading to P.C.
- Past and present symptoms – once, twice, all the time, previous restorations
- Procedures or trauma
Clinician led conversation to produce clear and concise narrative
Clinical Notes 26/07/18
- C/O -*
- HPC – (Use SOCRATES)*
- PMH -*
- PDH -*
- Social History - Exam*
- E/0 (TMJ, nodes, swelling or asymmetry)*
- I/O – endo assessment and BPE*
- Special investigations - Diagnoses - Treatment options and risks / prognosis - Agreed treatment – Signed /date*
pain originations
- Odontogenic
- Non odontogenic
- Trigeminal nerve branches
- Ophthalmic
- Maxillary
- Mandibular
- Primarily transmit pain in response to thermal, mechanical, or chemical stimuli
a delta nerve fibres
myelinated
sharp pricking sensaiton
early shooting pain
c fibres
unmyelinated
dull aching or burning
late dull pain
endodontic emergency
Pain and or swelling caused by various stages of inflammation or infection of the pulpal and/or periapical tissues.
- Cohens pathways of the pulp
- Many pt think that if nerve/pulp removed then no more pain, but inflammation of PDL and alveolar bone still possible
pain definition
an unpleasant feeling often caused by intense or damaging stimuli, such as stubbing a toe, burning a finger, putting alcohol on a cut, and bumping the funny bone
agony definition
Acute physical or mental pain or anguish
The suffering or struggle preceding death
Qs to ask relating to pain
- Where is the pain ? (maxilla / mandible , front or back of mouth)
- What does it feel like (short sharp / dull ache)
- How bad is it?
- How long is it there for? ( constant/ few minutes)
- Does anything take pain away? (pain killers / cold)
- What makes it worse? (heat, chewing)
- 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?
referred pain
- Perception of pain in one part of body distant from source of pain
- Difficult to discriminate location of pulpal pain – esp in heavily restored dentition
Referred pain usually provoked by intense stimulation of C-fibres leading to intense slow, dull pain
Always radiates to ipsilateral side
- Anterior teeth seldom refer pain to other teeth or opposite arch
- Posterior teeth often refer to opposite arch or periauricular area, but seldom to anterior teeth
- Mandibular posterior teeth refer pain to periauricular area more often than maxillary
MHx inc
Medical conditions and medications that impact on management
Medical conditions that may have oral manifestations or mimic dental pathosis
dental origins of TB and lymphoma
lymph node involvement
dental origins of leuakaemia and anaemia
paraesthesia
dental origins sickle cell anaemia
bone pain
dental origins multiple myeloma
tooth mobility
dental origins MS, acute maxillary sinusitis, trigeminal neuralgia
pain
clinical reasoning
Why do we decide to do what we do?
- Critical thinking
- Decision making.
Clinical reasoning. Clinical judgement
how do we process info
- Higher order thinking in which the health care provider, guided by best evidence or theory, observes and relates concepts and phenomena to develop an understanding of their significance.
- The use of a patient’s history, physical signs, symptoms, laboratory data, and radiological images to arrive at a diagnosis and formulate a plan of treatment.
The way we assimilate and interpret information has implications for the treatment we provide. Critical reasoning /decision making can be affected by attitude, preconceptions, bias, previous experience or perspective. Mood? Time?
- Even though we have the right information do we make the correct decision?
- The fear of shame
- Saying I don’t know
- Educated guesswork?
- Protecting your reputation?
process of examination
systematic
document the process
think
discuss process and findings with pt
endo exam
Extraoral exam
Intraoral exam
- Soft tissue exam
- Intraoral swelling
- Sinus tracts – communications between route and oral cavity
- Palpation
- Percussion
- Mobility
- Periodontal exam – long deep pockets = crack
EO assessments
- cellulitis
- Ludwig’s angina – compromise airway
- Swelling to eye
Emergency – refer immediately max fax/oral surgery
IV antibiotics, surgical incision potential
extra oral sinus - pus breaking through skin
soft tissue assessment
swellings lumps bumps abnormal
hard tissue assessment
Is the tooth restorable? Caries free, amalgam, crown placement
root fracture assessment
Excavator between cusps can tell if tooth split
Radiographs can help detect if crown on tooth
sensibility/vitality testing
Pulp tests
- Thermal
- Electric
- Laser doppler flowmeter
- Pulse oximetry
Sensibility not vitality
- Subjective (can be misinterpreted by pt)
- Contra-lateral teeth should be tested
- Assumption made that nerve fibres in pulp correlates to intact blood supply
- not appropriate
- problems with multi rooted teeth
cold sensibility
- Hydrodynamic forces
- Cold/Hot tests
- Frozen Carbon Dioxide (-78 degrees celcius)
- Ice less reliable
- Ethyl chloride
- Refrigerant spray
- Dry and isolate
- Close to pulp horn
- Fairly reliable
heat tests
- Too much heat may cause irreversible pulpitis
- Hot gutta percha – use Vaseline
- “Hot” water and dental dam
electric pulp tests
Electric current used to stimulate sensory nerves
- Primarily A-delta fast conducting fibres
- Unmyelinated C-fibres may or may not respond
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
No indication of reversibility of inflammation
No correlation between threshold and pulp condition
Negative response reliable indicator (generally)
EPT of teeth with open apices unreliable
clinical note
pulp test grid
e.g. special tests
- Bite test (fracture finder or tooth sleuth/sloth)
- Test cavity – drill into tooth, multi rooted tooth limited effect and not popular
- Staining and trans-illumination
- Selective anaesthesia
radiographic examination and interpretation
One of most useful diagnostic tests, but can make premature diagnoses based on them
Without a proper history and clinical exam and testing a radiograph alone may lead to misinterpretation of normality and pathosis
- Do not look at radiograph in isolation
Two pre-op radiographs from different angulations
Subjective nature of the radiographic appearance of endodontic pathosis
CBCT
sinus tract tracing
GP cone into sinus and see if tracks into particular tooth
Infection source
clinical notes - radiographic report
PA of tooth 46: Grade A (what of and what grade)
Shows
- Large restoration, deep distally
- Recession of pulp
- No obvious PA lesion present
- Pulp chamber reduced in size, canals visible in middle, coronal third, not at apex
- Perio bone level adequate
Remember the other teeth! (48,46,45,44 present)
- Occlusal restoration 45, no PA lesion
- 44 unrestored, no pa lesion
- Calculus interproximally
- Perio - bone levels
areas to think of in dx
Top of tooth (crown)
Middle of tooth (pulp)
Bottom of tooth (apex, bone, and soft tissue)
categories for pulpal dx (7)
- Normal Pulp
- Reversible Pulpitis
- Symptomatic Irreversible Pulpitis
- Asymptomatic Irreversible Pulpitis
- Pulp Necrosis
- Previously Treated
- Previously Initiated Therapy
apical dx categories (6)
- Normal Apical Tissues
- Symptomatic Apical Periodontitis
- Asymptomatic Apical Periodontitis
- Chronic Apical Abscess
- Acute Apical Abscess
- Condensing Osteitis
tx options (5)
- Root canal treatment
- Re root canal treatment
- Extract the tooth
- Monitor / don’t intervene
- Surgical intervention
dx challenges
use history and examination to pinpoint pain
getting it wrong
clinical notes
dx
Diagnosis tooth 46 – Secondary caries, irreversible pulpitis Apical periodontitis.
- (If they had swelling also be acute apical abcess)
- Multiple diagnoses for one tooth
Treatment options
- Monitor - ? Risks and prognosis
- Root canal treat – risks and consent
- Extract – risks and prosthetic options
- Surgery – not first line treatment
