L8. Diagnosis in Endodontics Flashcards
Who is considered the godfather of modern Endodontics?
Herbert Schilder
What is the definition of a diagnosis?
The identification of the nature of an illness or other problem by examination of symptoms
What are the three branches of the trigeminal nerve?
- Ophthalmic;
- Maxillary;
- Mandibular.
What are the two types of nerve fibres involved in dental pain?
- A-delta fibres;
- c-fibres.
What type of pain do A-delta fibres transmit?
Sharp, pricking sensation (early shooting pain)
What type of pain do c-fibres transmit?
Dull, aching or burning pain (late dull pain)
What is the definition of an endodontic emergency?
Pain and or swelling caused by various stages of inflammation or infection of the pulpal and/ or periapical tissues
What is pain?
An unpleasant feeling caused by intense or damaging stimuli
What is referred pain?
Perception of pain in one part of the body, distant from the source of pain (usually provoked by c-fibres)
Which teeth typically present with referred pain and where to?
- Posterior teeth - to opposite arch or periauricular area;
- Mandibular posterior teeth refer pain periauricularly more than maxillary teeth.
What common medical conditions can cause non odontogenic dental pain?
- TB/ lymphoma: lymph node involvement;
- Leukaemia/ anaemia: paraesthesia;
- Sickle cell anaemia: bone pain;
- Multiple myeloma: tooth mobility;
- MS/ acute maxillary sinusitis/ trigeminal neuralgia: pain.
What’s involved in an endodontic examination?
- E/O exam;
- I/O exam;
- Soft tissue exam;
- I/O swelling;
- Sinus tracts;
- Palpation;
- Percussion;
- Mobility;
- Periodontal exam.
What are the two main types of sensibility testing?
- Thermal;
- Electric.
What are the issues with sensibility testing?
- Sensibility, not vitality (i.e. checks sensation within a tooth, not blood supply);
- Subjective;
- Contra-lateral teeth need to be checked too;
- Assumption that nerve fibres in the pulp correlate to intact blood supply (not the case);
- Problems with multi-rooted teeth (i.e. some roots can be vital, others not but can’t distinguish difference).
How do cold sensibility tests work?
- Movement of dentinal fluid;
- Hydrodynamic forces stimulate nerve;
- Can use: frozen carbon dioxide, ethyl chloride, refrigerant spray etc.
- Dry and isolate tooth;
- Apply close to pulp horn.
How do hot sensibility tests work?
- Movement of dentinal fluid;
- Hydrodynamic forces stimulate nerve;
- Can use: hot GP and vaseline;
- Dry and isolate tooth;
- Apply vaseline;
- Apply hot GP.
How do electric pulp (EPT) sensibility tests work?
- Use of electric current to stimulate nerve fibres;
- Primarily A-delta fibres;
- Dry and isolate tooth;
- Conducting medium used to complete circuit;
- Ask pt to place probe on tooth;
- Current slowly increases until response (pt will often remove probe when they feel this);
- Record voltage.
What are the issues with EPT?
- No indication of reversibility of inflammation;
- No correlation between threshold and pulp condition;
- Unreliable with open apices.
What control is used for sensibility testing?
Testing contralateral teeth
What other special tests are sometimes used to direct a diagnosis?
- Bite test (frac finder or tooth sleuth);
- Test cavity;
- Staining and trans-illumination;
- Selective anaesthesia (does the pain diminish once anaesthetised?);
- Radiography.
What can be a useful way to divide the tooth when trying to reach/ thinking about a diagnosis?
- Top of tooth (crown);
- Middle of tooth (pulp);
- Bottom of tooth (apex, bone and soft tissue).
What are the 7 possible pulpal diagnoses?
- Normal pulp;
- Reversible pulpitis;
- Symptomatic irreversible pulpitis;
- Asymptomatic irrversible pulpitis;
- Pulp necrosis;
- Previously treated;
- Previously initiated therapy..
What does a diagnosis of ‘normal pulp’ indicate?
- Symptom free;
- Normally responsive (mild or transient response to cold testing);
- Does not mean pulp is histologically normal.
What does a diagnosis of ‘reversible pulpitis’ mean?
- Inflammation should resolve upon management of aetiology;
- Discomfort experienced when a stimulus is applied, but only lasts a few seconds;
- Can be caused by significant caries, deep restorations or exposed dentine;
- No significant radiographic changes.
What does a diagnosis of ‘symptomatic irreversible pulpitis’ mean?
- Vital inflamed pulp, incapable of healing - RCT or extraction indicated;
- Sharp pain with hot stimuli, lingers after removal of stimuli;
- Pain may be accentuated when lying down/ bending over;
- If inflammation is yet to reach periapical tissues - no pain to percussion;
- OTC medications not effective;
- Can be caused by deep caries, extensive restorations or fractures exposing pulpal tissues.
[classic toothache]
What does a diagnosis of ‘asymptomatic irreversible pulpitis’ mean?
- Vital inflamed pulp, incapable of healing - RCT or extraction indicated;
- No clinical symptoms, usually respond normally to thermal stimulation;
- Can be caused by deep caries (i.e. excavation of caries would expose pulp)..
What does a diagnosis of ‘pulpal necrosis’ mean?
- Nerve within tooth is dead (liquified);
- Non-responsive to pulp-testing;
- Asymptomatic.
What does a diagnosis of ‘previously treated’ mean?
- Previous endodontic tx carried out;
- Canals may be obdurated;
- Tooth probably will not respond to pulp-testing however in multi-rooted teeth, they can (due to vital nerve present).
What does a diagnosis of ‘previously initiated’ mean?
- Previous root procedure has not been completed;
- May be asymptomatic;
- RCT or extraction indicated.
What are the 6 possible apical diagnoses?
- Normal apical tissues;
- Symptomatic apical periodontitis;
- Asymptomatic apical periodontitis;
- Chronic apical abscess;
- Acute apical abscess;
- Condensing osteitis.
[sometimes more than one applicable]
What does a diagnosis of ‘normal apical tissues’ mean?
- Not sensitive to percussion or palpation;
- Radiographically the lamina dura and periodontal ligament are intact and uniform.
What does a diagnosis of ‘symptomatic apical periodontitis’ mean?
- Inflammation of the apical periodontal tissues;
- Usually sore to touch/tap;
- May or may not see radiographic changes (e.g. radiolucency, osseous breakdown).
What does a diagnosis of ‘asymptomatic apical periodontitis’ mean?
- No clinical symptoms;
- Not sore to bite on or percuss;
- Tooth may or may not have been root treated;
- Seen by radiolucency.
What does a diagnosis of ‘chronic apical abscess’ mean?
- Can be symptomatic or asymptomatic;
- Sinus tract may have formed;
- Pt might complain of lump or bump that sometimes discharges;
- Usually this is not too uncomfortable.
What does a diagnosis of ‘acute apical abscess’ mean?
- Inflammatory reaction to pulp an infection/ necrosis;
- Rapid onset;
- Pain/ extreme tenderness;
- Swelling;
- May not see radiographic changes due to quick onset;
- Pt might experience other symptoms malaise, fever etc.
What does a diagnosis of ‘condensing osteitis’ mean?
- Localised bony response to inflammation;
- Normally around apex of tooth;
- Seen by dense, boney appearance on radiograph;
- May respond positively.
What are the available treatment options in endodontics?
- RCT;
- Re-RCT;
- Extraction;
- Monitor/ don’t intervene (must inform pt of risks);
- Surgical intervention.
