Treatment of different forms of periodontitis Diagnosis and Treatment Planning

1. Treatment of different forms of periodontitisDiagnosis 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 • Diabetes • Pregnancy • Written consultation with physician as required

5. 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

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

7. 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

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

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

10. Pain History

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

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

13. Pulpal Pain

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

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

16. Periradicular /Periodontal Pain

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

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

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

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

21. Extra-oral Swelling

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

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

24. Acute apical abscess Acute apical abscess Incision and drainage

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

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

27. Discoloration

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

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

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

31. 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

32. Percussion Test Vertical percussion Horizontal percussion

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

34. 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

35. Palpation

36. 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

37. 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

38. Thermal Tests

39. Thermal Tests CO2 Snow Ice stick

40. 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

41. 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)

42. 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

43. 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

44. Electric Pulp Test

45. 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

46. Electric Pulp Testing

47. 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

48. Periodontal Examination

49. Periodontal Examination An isolated deep pocket may indicate a root fracture

50. Selective Anesthesia • May help to identify the possible source of pain • Ability to anesthetize a single tooth has been questioned