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1. DIAGNOSIS & TREATMENT PLANNING in endodontics BY: CHAITRA DEVI By Chaitradevi

2. Introduction: • Before initiating dental Rx,one must 1st assemble collective information regarding the signs,symtoms & history,& then this information is combined with results from clinical examination & tests,& this process is called Diagnosis.

3. Accurate diagnosis can only result from the synthesis of scientific knowledge, clinical experience,intutions & common sense, therefore diagnosis is both an art & science. • Diagnostician must have thorough knowledge of the pathosis,R/G & clinical manifestation,examination procedures & the Rx modalities.

4. And above all skills, one must learn to listen to the pts problem patiently.

5. Definitions of Diagnosis: • Ingle: Diagnosis is a procedure of accepting pt recognising that he/ she has a problem, determining cause of the problem & developing a Rx plan that will solve this problem. • Stedman’s medical dictionary :Clinical diagnosis described as “the determination of the nature of disease made from a study of the signs & symptoms of the disease”

6. Gunnar Bergen Holtz: It’s the art of distinguishing one disease from the other. • VimalSikri: Utilization of scientific knowledge for identifying a disease process & to differentiate it from other diseases

7. SOAP FORMAT: • The SOAP format, is best used for patient evaluation and diagnosis,it designates: • Subjective: Information obtained from the patient and family members. • Objective: Data obtained from observation, physical examination, or diagnostic test results. • Assessment/Appraisal:it is the dentist’s diagnosis based on subjective and objective findings. • Plan:The planned treatment.

8. Symptoms: • Its defined as phenomenon or sign of a departure from the normal & are indicative of illness. • Classified as: 1.Subjective symptoms :Those experienced & reported by the pt to the clinician. 2.Objective symptoms: Those ascertained by the clinician through various tests.

9. Assessment: • Diagnostic tests are usually assessed in terms of specificity & sensitivity. • Specificity: Ability of the test or observation to clearly differentiate one disease from another. • Sensitivity: Ability of the test or observation to detect the disease when ever it is truly present.

10. Diagnosis starts the moment the pt enters the clinic.Pt’soveralassessment,his way of dressing,gait & general wellbeing should be noticed at first instance. • Excitement & apprehension on the face of the pt should also be calculated,& by this time pt is socially & psychologically assessed.

11. Clinical diagnosis can be ÷ into : • History taking & • Clinical tests

12. History taking: • A complete history will not determine the Rx but may influence modification in endodontic Rx modalities. • Good history must record: 1.Bio data 2.Chief complaint 3.History of presenting illness 4.Past dental history 5.Past medical history

13. Biodata: 1. Name: • Identification. • Maintain records. • Better Communication. • Psychological benefit

14. Age: Eg:if there is complete absence of teeth even at the age of 4-5 yrs Hereditary ectodermal dysplasia may be suspected. Pulp chambers are placed at a higher level in young permanent teeth so care to be taken while working on such teeth. More the chances of obliterated root canals in aged teeth.

15. 3.Sex: • Incidence of certain disease more in certain sexes eg: • Females-iron deficiency anemia,caries,Sjogrens’ssyndrome,torus palatines etc • Males-Attrition,carious deciduous teeth,leukoplakia,Ca of buccal mucosa etc.

16. 4.Address: It is necessary for future correspondence with the patient ,few diseases have geographic prevalence. eg: Dental caries and mottled enamel are dependant on fluoride content of domestic water,caries more common in modern industrialized area while pdl diseases are more common in rural areas.

17. 5.Occupation: Hepatitis B-dentists, surgens,blood bank personnel. Gingival staining – strange dark staining of marginal gingiva seen in persons working with lead,bismuth,cadmium.

18. Attrition –seen in patients exposed to atmosphere of abrasive dusts & cannot avoid getting the material into his mouth. Habitual opening of pins may result in notching of incisal edges as seen with carpenters,shoemakers or tailors.

19. 6.Religion & 7.Marietal status are the other things to be included in the biodata.

20. Chief complaint: Is the reason for which the pt comes to the doctor or the reason for seeking treatment.It should be recorded in patients own words & attention should be given 1st to It.If few complaints start simultaneously it should be recorded in order of severity.

21. History of presenting illness: The development of pt’s history is a interview process during which the dentist attempts to evaluate pt’s symtomsaccurately,completely & objectively avoiding temptation to make a premature diagnosis.

22. Pain is frequently main component of chief complaint & therefore questions should be asked regarding 1.Onset of pain 2.Kind/type of pain 3.Duration of pain 4.Aggrivating &relieving factors, 5.Whether it is referred to another site or not

23. Onset of pain: sudden or gradual • Type of pain: Sharp,piercing & lancinating– Due to the excitation of A-δ fibers of the pulp,this pain reflects on the reversible state of the pulpitis. Dull,boaring,& extruciating pain due to exicitation & slower rate of transmission of C-fibers of pulp.This pain reflects on the irreversible state of pulpitis.

24. Duration of pain: If pulpal pain remits relatively “quickly”within few sec after stimulus removed,it is pressumed to be suffering from reversible pulpitis. While if pulpal pain “lingers” for 30 sec or more after stimulus is removed,indicative of irreversible pulpitis.

25. Localization of the pain: Pain is localized when pt can point to spot a specific tooth or site with assurance & the speed when asked to do so. • Referred pain : Perception of pain in one part of body that is distant from the actual source of pain.

26. Pain of non-odontogenic origin can refer pain to the teeth,teeth may also refer pain to other teeth as well as to other anatomic areas of head & neck. • Referred pain from tooth is usually provoked by an intense stimulation from C-fibers in pulp,which causes an intense slow,dull throbbing pain.

27. Referred pain always radiates to the ipsilateral side of tooth involved. • Ant teeth seldom refers pain to other teeth or to opparch,whereas post teeth may refer pain to the opposite arch or to the preauriculararea,but seldom to ant teeth.

28. Past dental history: Highlights pt’s attitude towards dental Rx,what sort of dental Rx done before & complications if any occurred. Also the allergy to dental ointments,pastes, mouthwashes,LA should be noted.

29. Past medical history: This gives information about any significant or serious illness a pt may have or had as a child or adult. Specific questions regarding heart,liver,kidney or lung diseases,diabetes,radiation, allergic rxns,infectious diseases, cancer chemotherapy & bleeding disease should be asked.

30. Any pt with the history of rheumatic fever has the potential of suffering sub acute bacterial endocarditis after any bacteremia,because every dental procedure has the potential to cause some degree of bacteremia,definite measures should be taken to avoid the possibility of SABE. • Often pt with previous h/o coronary occlusion is receiving anticoagulants.

31. Non-surgical endodontic treatment-no alteration in administration of anticoagulants. • If surgery becomes mandatory-pts physician to be contacted.

32. It was suggested to avoid L.A with epinephrine while Rx pts.withHTN,unfortunately L.A without epinephrine has less profound effect & shorter duration of action than those containing it. Pain felt by pt may produce much more endogenous epinephrine than that included in anaestheticsoln,for this reason epinephrine content of 1:1,00,000 is considered apt.

33. No more than 3 carpules of anaestheticsoln should be used at single appointment. • In severe haemophilics bleeding from pulp & periapical tissue can be persistent & troublesome.If the tooth to Rx is necrotic no L.A is needed. • Topical application of 10% cocain is recommended for vital tooth extirpation.

34. If conservative Rx is not feasible without L.A intraligamentaryinj is unlikely to cause any bleeding.Care to be taken while placing matrix bands to avoid any trauma. • Healing is retarded & it should be considered while evaluating pt with DM. • Periodic post operative check up R/G’s to be taken as R/L are slower to fill with bone than in normal pt’s.As these pt’s are more prone to inf antibiotics to be employed in presence of inf or if surgical procedure is to be carried out.

35. L.A with epinephrine is not recommended in DM pts as it inc the blood sugar level by stimulating the sympathetic nervous system,& also because these pts suffer from capillary ischemia due to atherosclerosis,incepi causes tissue sloughs after surgical procedure(levonordefrin-vc sub). • Special attention to be given to pt’s with MI,asthma,epilepsy,allergies,TB,HIV.

36. Family history: • Certain conditions are likely to be inherited like DM,hemophilia,HTN etc & should be explored by asking series of questions.

37. Personal history: Should include asking about oral hygiene habits,pressure habits like thumb sucking,fingersucking,tonguethrusting,mouthbreathing,bruxism or bruxomania .

38. Vital signs: • They are useful as an indicators of systemic disease,in addition this information is also essential as a standard reference should the syncope or other untoward medical complication arises during patient treatment. • Normal respiratory rate during rest-14-16 breath/min. • Tachypnea(rapid breathing): >20breaths/minute.

39. Body temp in dental pt is checked in case systemic illness or systemic response to secondary dental infection(bacteremia). • Recent drinking of cold or hot drinks or mouth breathing in warm or cold air alters the oral temp. severe oral infection may alters the local oral temp,even in the absence of fever.

40. Normal body temp- Oral(sublingual)-98.6°F/37.0°C - Aural-99.6°F/37.7°C -Axillary-97.6°F/36.3°C • Pulse rate: 60-100beats min-normal <60beats/min-Bradycardia >100beats/min-Tachycardia.

41. B.P: normal:120/80mm Hg for the person under the age of 60yrs;130/90mm Hg over the age of 60yrs. B.P should be controlled before starting any surgical Rx & when diastolic B.P is 100mm Hg or above no pt with or without dental emergency should be Rx unless its got under control.

42. EXTRA ORAL EXAMINATION TMJ • Lymph nodes • Swelling • Facial asymmetry • Extra oral sinus tract.

44. Intra oral examination: 1.Visual examination: • A thorough visual, tactile examination of hard and soft tissues relies on three “3Cs” – i.eContour, Colour and Consistency”. • In soft tissues such as gingiva any deviation from healthy,pinkcolour is readily recognized when inflammation is present. • While in case of hard tissue normal appearing tooth has life like Translucency.

45. Discolorations could be due to necrotic pulp,oldamalgumresto,Rc filling materials & medicaments,tetracycline staining etc. • A change in gingival contour occurs when there is infm & swelling.

46. Change in crown contor can occur due to #,wear faecets , restorations,developmental defects etc. • A change in consistency from normal healthy firm gingiva to soft,fluctuant or spongy one indicates pathological condition. • Consistency of hard tisue relates to the presence of caries,internal & external resorption.

47. Visual examination should be carried out under good light under dry condition,if not • In the presence of saliva & packed food may mask the presence of sinus tracts,interproximal caries etc. • Loss of translucency,slightdiscoloration,cracks may also go unnoticed.

48. Percussion: Tenderness on percussion does’nt indicate that tooth is vital or non-vital,rather an indication of inflammation in periodontal ligament. Inflammation may be secondary to Physical trauma,occprematurities,periodontal diseases or extention of pulpal disease into PDL space.

49. Tooth is percussed in vertical & horizontal direction initially with low intensity by index finger,if the pt cannot detect any significant difference b/w any of the tooth& then test is repeated with back end of mouth mirror with inc intensity. • The contralateral tooth should be 1st tested as a control,as well as several other teeth that are certian to respond normally & then the tooth of interest.

50. Although it is a simple test if it is used alone may be misleading,to eliminate this bias on the part of the pt,1 must change the sequence of the teeth percussed on successive tests. • A dull note on percussion signifies abcess formation & sharp note merely means inflammation. • It must be noted that a tooth must not be percussed beyond the pts tolerance.