W7 - Endodontic Diagnosis - Amaral Flashcards
5 stages of making a diagnosis
- Pt reasoning for visiting clinician
- Symptoms and history
- Objective clinical tests
- Clnician correlates objective findings with subjective details and creates a list of Diff dx
- Definitive diagnosis formed
Why must intraoral swellings be palpated?
Want to determine whether they are diffuse or localised, and firm or fluctuant
What does percussion test indicate
Pain to percussion does not indicate that the tooth is vital
or nonvital but is rather an indication of inflammation in
the PDL
What may a localised narrow perio pocket that extends deep down while adjacent periodontium is WNL indicate?
Vertical root fracture
Sensibility vs vitality
Vitality - blood flow, oxygen presence
Sensibility - nerve intact
3 ways of testing pulp sensibility
Application of:
Mechanical
Electrical
Thermal Stimuli
What are abnormal responses to cold test
Lack of response
Lingering pain
Immediate, excruciating pain
What does EPT look for?
Presence of viable nerve fibers in pulp that are capable of responding
What can a false positive EPT response mean? (4)
False positive responses
- could be partial pulp necrosis
- could be due to high anxiety
- Ineffective tooth isolation
- Contact with metal restorations
What may false negative responses of EPT indicate? (4)
obliteration
recently traumatized tooth
Immature apex
Drugs that increase pain threshold (antidepressant)
2 vitality tests
Laser doppler flowmetry
Pulse oximetry
**not really used in clinics*
Test used for suspected fracture
Bite test / frac finder
What special test to be done IF ALL OTHER TESTS FAIL to assess sensibility of tooth
Test cavity
- No anethesia
- Want to see if pt has any sensation during drilling
What test to do when symptoms are not localized or are referred and pulp testing is inconclusive
Selective anesthesia
Should diagnosis be made with radiograph only?
No
Image should be used only as one sign, providing important clues in the diagnostic investigation.
When history, clinical examination and testing not assessed with the radiograph, it can lead to misdiagnosis
Dens invaginatus
What should be requested if treated tooth is flaring up or if PA radiograph unable to see all detail
CBCT
4 diseases of the pulp
Reversible pulpitis
Irrev pulp
Asymptomatic Irrev pulp
Necrosis
What is dentin sensitivity
Exposed dentin wihout signs of pulp pathosis
- Sharp, quickly reversible pain
- In response to thermal, tactile, mechanical osmotic or chemical stimuli
subcategories of irrev pulp
Symptomatic - exposure to cold will elicit prolonged pain
Pain can be sharp or dull, localised, diffuse or reffered
Asymptomatic
What happens in pulp necrosis
Pulpal blood supply is non existent and the pulpal nerves are nonfunctional
- This condition is preceded by irrev pulp
- Asymptomatic until disease extends periapically
necrosis may be partial or complete, and may not involve all canals in a multirooted tooth
How does necrotic pulp respond to special tests
Unresponsive to EPT and cold
If heat is applied for extended period of time, it may respond (will be relieved by cold)
*
4 apical diseases
Symptomatic apical periodontitis
Asymptomatic apical periodontitis
Acute apical abscess
Chronic apical abscess
Features of asymptomatic apical periodontitis (3)
“Feels different” on percussion, but not painful
Apical radiolucency
No clinical symptoms (pain)
Features of symptomatic apical periodontitis (3)
Painful clinical symptoms
Painful response to TTP
MAY or MAY NOT have apical radiolucency
Features of acute apical abscess (3)
Radiograph can exhibit anything from widened PDL up to apical radiolucency
Swelling present intraorally or facially
Pt frequently febrile, lymph nodes will be tender to palpation
What is phoenix abscess?
Acute exacerbation of a chronic periapical lesion
Abscess that can occur immediately following RCT
Due to untreated necrotic pulp (chronic apical periodontitis). Or inadequate debridement during the procedure
Features of chronic apical abscess (4)
Minimal or no pain
Sinus tract
Apical radiolucency
Tooth not sensitive to biting pressure but “feels different” to TTP
- “This entity is distinguished from asymptomatic apical periodontitis because it will exhibit intermittent drainage*
- through an associated sinus tract.”*
What must be considered before performing endo tx? (5)
Is the problem of dental origin?
Is the pulp pathologically involved?
Why is the pulpal pathogen present?
Prognosis?
What is the appropriate form of treatment?
Radiographic changes in pulpal necrosis
Thickening of PDL space or PARL
For your own knowledge
Why is asymptomatic irrev pulp painless?
Bc the pulp is exposed to the oral cavity
- It’s inflamed and swells up, however since it is exposed, there is no pressure build up (expands like polyp)
- Symptomatic irrev pulp is painful because the pulp is still bound to chamber (dentine above) → no room for swelling = no pain relief
