Diagnosis and Treatment Planning

1. Diagnosis and Treatment Planning

2. Definition Diagnosis is the determination of the nature of a diseased condition by careful investigation of its symptoms and history

3. Sequence of Events • Medical History Review • Subjective History • Objective Testing • Analysis of data collected – Clinical diagnosis • Plan of Action

4. Medical History Review • Review/update written medical questionnaire • Medications • Allergies • Need for SBE prophylaxis • Diabetes • Pregnancy • Written consultation with physician as required

5. Medical History Review SBE Prophylaxis • Required for endodontic treatment in at risk patients • AHA recommendations should be followed

6. Medical History Review • Prescribe: • 2 grams Amoxicillin 1 hour prior to treatment • Clindamycin 600 mg for penicillin allergic patients

7. Medical History Review Diabetes • Do not treat uncontrolled diabetics • Schedule appointment for early morning • Ensure that patient has had morning insulin and breakfast • Have a source of sugar readily available

8. Medical History Review Pregnancy • Avoid treatment in first and third trimesters • Keep radiographic exposure to a minimum

9. Medical History Review Latex Allergy • Non-latex rubber dam • Latex-free gloves • One report of allergy to gutta-percha – no definitive proof that a true allergic reaction occurred • Consult patient’s allergist

10. Medical History Review The only systemic contraindications to endodontic therapy are: • Uncontrolled diabetes • A very recent myocardial infarct

11. Subjective History Chief complaint • In patient’s own words • “My tooth hurts when I chew hard foods” • “I can’t drink cold soda”

12. Pain History

13. Subjective History Pain History • Location • Intensity • Duration • Stimulus • Relief • Spontaneity

14. Pulpal Pain Very poorly localized • Intermittent • Throbbing • Intensified by heat, cold and sometimes chewing • May be relieved by cold • Usually severe

15. Pulpal Pain

16. Periradicular Pain • May be well localized • Deep pain • Intensified by chewing • Moderate to severe in intensity

17. Periodontal Pain • May be well localized • Intensified by chewing • Moderate to severe in intensity

18. Periradicular /Periodontal Pain

19. Subjective History • Gives rise to tentative diagnosis • Determines urgency of treatment • Confirmed by examination and special tests

20. Objective Testing • Visual Examination • Radiographs • Percussion • Palpation • Mobility • Thermal tests

21. Objective Testing • Electric Pulp Test • Periodontal probing • Selective anesthesia • Test cavity • Transillumination • Occlusion

22. Visual Examination • Extra-oral examination • Facial asymmetry • Swelling • Extra oral sinus tract • TMJ

23. Extra-oral Swelling

24. Visual Examination Extra oral sinus tracts associated with necrotic teeth

25. Visual Examination Intra-oral examination • Soft tissue lesions • Swelling • Redness • Sinus tract

26. Acute apical abscess Acute apical abscess Incision and drainage

27. Visual Examination A sinus tract should be traced with a gutta-percha cone

28. Visual Examination Hard tissues • Caries • Large or defective restorations • Discolored/chipped teeth

29. Discoloration

30. Radiographs • Always take your own pre-operative radiograph • Never make a diagnosis based on radiographic evidence alone

31. Radiographs • Consider taking a bitewing film of posterior teeth • Note characteristic appearance of fractured root

32. Radiographs Characteristic J-shaped or halo lesion associated with fractured root

33. Percussion Test • A very significant test • Always compare suspect tooth with adjacent and contralateral teeth • Tenderness indicates inflammation in the PDL • Cause of inflammation may be pulpal or periodontal

34. Percussion Test Vertical percussion Horizontal percussion

35. Percussion Test Tooth Slooth Used to assess cracked teeth and incomplete cuspal fractures

36. Palpation Test • Extraoral • To detect swollen or tender lymph nodes • Intraoral • May detect early periapical tenderness • Identifies soft tissue swelling • Must compare with other areas

37. Palpation

38. Mobility • Reflects the extent of inflammation in the PDL • Compare with adjacent and contralateral teeth • There are many causes of mobility besides pulpal inflammation extending into the PDL

39. Thermal Tests • Cold always used • Heat rarely used • Compare reaction with adjacent and contralateral teeth • Refractory period of at least 10 minutes before pulp can be retested accurately

40. Thermal Tests

41. Thermal Tests CO2 Snow Ice stick

42. Thermal Tests • Isolate area with cotton rolls • Dry teeth to be tested • Ask patient to: • “Raise hand on feeling cold” • “Lower hand when cold feeling goes away” • Record: • + or – sensitivity to cold • Time until cold sensitivity was felt • Time that cold sensitivity lingered

43. Thermal Tests Classic Responses to Thermal (cold) Testing: • Normal Pulp: Moderate transient pain • Reversible Pulpitis: Sharp pain; subsides quickly • Irreversible pulpitis: Pain lingers • Necrosis: No response (Note false positive and false negative responses common)

44. Electric Pulp Test • A direct test of nerve elements of pulpal tissue • Vitality versus non-vitality only – not whether vital pulp is normal or inflamed • In multi-rooted teeth, where one canal is vital – tooth usually tests vital • False positives and false negatives may occur

45. Electric Pulp Test False positive reading: • Electrode contact with metal restoration or gingiva • Patient anxiety • Liquefaction necrosis • Failure to isolate and dry teeth prior to testing

46. Electric Pulp Test

47. Electric Pulp Test False negative reading: • Patient is heavily premedicated • Inadequate contact between electrode and enamel • Recently traumatized tooth • Recently erupted tooth with open apex • Partial necrosis

48. Electric Pulp Testing

49. Periodontal Examination • Periodontal probing pocket depths must be measured and recorded • A significant pocket, in the absence of periodontal disease may indicate root fracture • Poor periodontal prognosis may be a contraindication to root canal therapy

50. Periodontal Examination