Chief Complaint

Dental History

Dental History Interview

What Indicate A Difficult Diagnosis?

Oral Examination

Clinical Tests

Radiographic Examination

Diagnosis And Treatment Plan

There are limited numbers of possible diagnosis for pulpal and periapical conditions, that includes:

Pulpal diagnosis: Normal Reversible pulpitis Irreversible pulpitis (symptomatic/ asymptomatic) necrosis

Periapical diagnosis: Normal Symptomatic apical periodontitis Asymptomatic apical periodontitis Acute apical abscess Chronic apical abscess Condensing osteitis

These will be discussed at the end of the article.

CHIEF COMPLAINT

This is the first information that volunteered by the pa-tient and should be recorded in the exact formula. It can help in both diagnosis and treatment plan because

these comments are direct and non-biased.

DENTAL HISTORY

Investigate past dental history for recent trauma, re-cent restoration or periodontal treatment, and previous treatment for TMJ dysfunction.

DENTAL HISTORY INTERVIEW

The dentist should interview (ask) the patient about the symptoms he has to get the full idea of what is hap-pening and why it is happening.Patient may complain from: Pain swelling Sinus tract Broken tooth Loose tooth Tooth discoloration Bad taste

endodontic diagnosis and treatment planOsama Asadi, B.D.S, Published for Iraqi Dental Academy Blog

The journey to definitive treatment begin with accurate diagnosis. However, accurate diagnosis is not al-ways possible, due to complexity of the symptoms and many diseases share the same signs and symptoms.Also it established that histological condition of the pulp does not relate to the sign and symptoms.The basic steps in diagnostic procedure are: Chief complaint History (medical and dental) Oral examination Clinical tests Data analysis and differential diagnosis Treatment plan

LECTURE OUTLINE

CHAPTER

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If patient complain of pain, ask him the following questions: When did pain begin? Where is the pain located? Is the pain always in the same place? What is the character of the pain (short, sharp, long,

lasting, dull, throbbing, continuous, occasional)? Doses the pain prevent sleeping or working? Is the pain worse in the morning? Is the pain worse when you lie down? Did or does anything initiate the pain (trauma, bit-

ing, thermal)? Once initiated, how long does the pain last? Is the pain continuous, spontaneous or intermittent? Does anything make the pain worse (hot, cold, bit-

ing)? Does anything make the pain better (cold, an-algesics)?

Similarly, if patient is presented with swelling, take history of:

When did the swelling begin? How quickly has the swelling increased in size? Where is the swelling located? What is the nature of the swelling (soft, hard, ten-

der)? Is there drainage from the swelling? Is the swelling associated with loose or tender

tooth?

WHAT INDICATE A DIFFICULT DIAGNOSIS?

The following presentations may indicate a case that is difficult diagnositically:

Patient can not localize the pain source No local dental cause for the pain can be identified

(no caries, no restoration, etc..) Pain is spontaneous or intermittent Stimulation of suspected tooth (using vitality tests)

does not produce symptoms More than one tooth is suspected Symptoms are bilateral Selective anesthesia fail to localize the source of

pain

EXTRAORAL EXAMINATION

Clinician should look and analyze the patient as soon as he enter the room. Look for general appearance, skin tone, facial asymmetry, swelling, discoloration, red-ness, extraoral scars, sinus tracts and lymphadenopathy.Palpation of face and neck area is also important, to check for swelling or tenderness. Many times these swelling are not clear visually, and require palpation to

identify. Palpation of cervical and submandibular lymph nodes is important part of diagnostic procedure. If there is swelling or feels firm and tender, with elevated tem-perature, then these is greater chance of systemic in-volvement.Loss of definition of nasolabial fold on one side of the nose may be the earliest sign of canine space infec-tion. This can result from infected maxillary canine, or long-rooted incisors.

INTRAORAL EXAMINATION

Oral tissue is dried and examination begin of the lips, oral mucosa, cheeks, tongue, periodontium, gingiva, palate and muscles.Look for any sign of discoloration, inflammation, ul-ceration, and sinus tract formation.Sinus tract can be traced to its source using gutta-per-cha points size #25 or #30 and inserted into the open-ing until resistance is felt. It may cause slight discom-fort to the patient.Examine teeth with mirror and explorer and look for discoloration, fracture, abrasion, attrition, erosion, car-ies, defective restoration, or other abnormalities.A discolored crown can be an indication of pulp pa-thosis.

PERIODONTAL EXAMINATION

MobilityExamine mobility of the tooth by placing the back end of mirrors on both buccal and lingual surface of the tooth, then apply pressure in bucco-lingual direction

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Figure 1. Look at loss of definition of nasolabial fold at the left

side of the face

and also in vertical direction. Any movement more than 1 mm should be considered abnormal.Increased mobility does not mean the pulp is not vital, mobility is an indicative of the status of the periodontal attachment.Increased mobility can occur due to trauma, occlusal prematurities, rapid orthodontic movement, parafunc-tional habits, periodontal diseases, root fracture or pul-pal diseases.

ProbingProbing is an important step in diagnosis. Teeth with wide periodontal pocket usually are periodontal in or-igin, while teeth with narrow localized pocket are usu-ally endodontic in origin, or could be vertical root frac-ture.Furcation bone loss could be periodontal or endodontic in origin, and should be recorded in the chart.

CLINICAL TESTS

These include:

Palpation percussion Thermal tests Electric pulp test Bite test Test cavity Staining and transillumination Selective anesthesia

These has been discussed extensively in previous lec-tures, however, a short overview will be presented here.

PALPATION

Firm digital pressure with index finger is applied to the apical area of the tooth, and adjacent teeth.Any soft tissue swelling, bony expansion should be noted and recorded. Pain or tenderness during the pro-cedure should be recorded too. This may indicate an active periapical inflammation, however, it does not determine whether it is endodontic or periodontal in origin.

PERCUSSION

This test is performed when the patient complain of pain during biting or mastication.Pressure is applied with index finger on the incisal/oc-clusal surface of the tooth vertically and horizontally. The adjacent teeth should be tested first to serve as con-trol and to know the normal response of the patient. If

patient does not report any pain after completing this test, then a blunt instrument is used to tap on the tooth.This test does not indicate the status of the pulp, rather it indicate presence of inflammation in the PDL.

THERMAL TESTS

These include cold test, and heat test.Cold test can be used with ice sticks, dry ice (co2), or refrigerant spray. Adjacent teeth should be isolated with gauze to prevent false-positive results, then cold instrument is applied to the tooth surface and response is waited. If patient response to the test and pain sub-side after removal of the instrument then the pulp is normal. If pain does not diminish or rather increase af-ter removal of the instrument then this tooth most likely has a pulpal pathosis.Heat test can be applied using heated water with syringe (after isolation with rubber dam), heated gutta-percha (remember to add lubricant to the tooth surface to pre-vent adhesion of gutta-percha to the tooth), or the use of rotating rubber cup (not recommended).Cold test has been reported to be equal or even superior to electrical pulp testing according to several studies.

ELECTRICAL PULP TEST

This test does not indicate the presence of vascular sup-ply in the pulp (a sign of vitality), but rather indicate the presence of intact nerve fibers.It has been reported that electrical pulp testing is most accurate when detecting necrotic teeth.Some studies has been reported that cold test has supe-rior advantage over electrical test, while some studies reported no significant difference between the two tests.

BITE TEST

It begin by applying firm pressure using cotton tip ap-plicator, toothpick, or tooth slooth on each cusp of the tooth. Patient will report pain when there is apical pathology or root fracture. Sometimes patient feel pain when the instrument is removed, which may indicate a fractured tooth or root.

TEST CAVITY

This test is not recommended because it is an invasive procedure. It only used when other test results failed to determine the condition of the pulp. A bur in high speed with water coolant is used to drill the tooth, when den-tin is reached the patient will feel pain which indicate vital pulp tissue. However, when no pain is felt then the tooth is necrotic and the procedure is continued to access opening and further endodontic treatment.

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STAINING AND TRANSILLUMINATION

Stains can be used to determine the presence of fracture in the root. Also tranillumination with strong fiberoptic light can determine the fracture site. Area that is close to the light source will appear bright, while area beyond the fracture will appear dim.

SELECTIVE ANESTHESIA

It used when other tests are inconclusive. PDL injec-tion is applied to each tooth, starting from the maxilla. A most posterior tooth should be anesthetized first and progressing anteriorly. If all teeth in maxilla anesthe-tized and pain is still present, the same procedure is ap-plied to the mandible until pain disappear.However, it should noted that PDL injection can anes-thetize more than one tooth at a time which make it less useful in determining which tooth is the source of pain. Therefore, this technique is most useful in recog-nizing which arch (maxilla or madibule) is the source, and not a specific tooth.

RADIOGRAPHIC EXAMINATION

The value of radiographic image are sometimes overes-timated by the clinician. Proper diagnosis and clinical tests are necessary, and radiograph is only supplemen-tary.Traditional radiography is two-dimensional presenta-tion of three-dimensional structures, therefore multiple radiograph should be taken from different angles to vi-sualize more hidden structures.A well-prepared radiograph can find multiple canals, multiple roots, resorption, caries, defective restoration, root fracture and state of root maturation and apical de-velopment.

Periapical pathology can be presented radiograph-ically with:

The lamina dura is absent apically Radiolucency at the apex

However, not all apical pathosis are seen on radiograph, especially early lesions.Studies has found that radiolucency on radiograph can be seen only when pathosis reach the cortical bone, it can not be seen when presented in cancellous bone.The root apecies of most anterior and premolars are close to the cortical bone, therefore seen early. While molar teeth are found in the cancellous bone, therefore not seen early in the radiograph. Absence of radiolucency in the the radiograph does not mean there is no pathology, other clinical tests should be performed to reach that level of diagnosis. 4

Lamina dura is the most consistent radiographic finding when tooth is not vital. If lamina dura is widened, or in-termitted then it can be an indication of pulpal pathosis.In addition to that, radiograph can shows presence of pulp calcifiction, or canal obliteration due to dentin for-mation, and these conditions are normal and need no intervention unless pulp is offended.It worth mentioning that more advance radiographic has been incorporated in dental practice in recent years with superior imagining qualities compared to conven-tional 2D radiograph.

DIAGNOSIS AND TREATMENT PLAN

Normal pulpThe tooth response normally to pulp tests. It response with pain to the tests when applied and pain is disap-pear after removal of the stimuli.

Reversible pulpitisIt mean that the pulp is inflammed but the condition is reversible. Pulp return to normal after removal of the cause. It usually presented with caries, defective restoration, exposed dentin, recent periodontal treatment.

TreatmentThe offending stimuli should be removed, and the tooth is restored. In case of deep caries, direct pulp capping technique is applied.

Irreversible pulpitisThe pulp is inflammed beyond repair. It can be subdi-vided into two categorizes: symptomatic and asymp-tomatic.

Symptomatic irreversible pulpitisThe pain usually spontaneous or intermittent. Response rapidly to thermal stimuli and pain persist even after removal of the stimuli. The pain could be sharp, dull, localized, diffuse or referred. Radiographically, it can be presented with widened PDL, however, sometimes no sign of pathology can be seen.When the patient presented with symptoms of symp-tomatic irreversible pulpitis in anterior teeth without any sign of caries or local factor, the patient should be ask of past history of general anesthesia or endotracheal intubation procedures. He also should be ask about any history of orthodontic treatment.

TreatmentRoot canal treatment

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Asymptomatic irreversible pulpitisIn this case, even that the tooth is presented with deep caries or apical or lateral radiolucency the patient com-plain of no symptoms.

TreamtentRCT should be done for this tooth as soon as possible so that it do not convert to symptomatic pulpitis or fu-ture necrosis occur with lingering pain.

Pulp necrosisThe pulp is dead and RCT is indicated. Tooth does not respond to electrical or cold test, however it may re-sponse to heat test if applied for long time. Thickened PDL can be seen on the radiograph.When necrosis is chronic the infection reach the peri-apical area and lead to apical pathosis which presented as radiolucency at the apex.

Symptomatic apical periodontitisThis condition is characterized by inflammation of peri-odontal area of the infected tooth. The tooth response to biting, percussion or palpation tests. The tooth may or may not response to vitality test. Radiographically, the tooth presented at least with widened PDL. Apical radiolucency may or may not be seen.

TreatmentRCT

Asymptotic apical periodontitisThe tooth usually does not response to vitality tests, and does not response to biting test but it feels different.The tooth usually exhibit apical radiolucency. Howev-er, patient does not complain of any symptoms

TreatmentRCT

Acute apical abscessThe patient complain of spontaneous pain, the tooth is tender to biting, percussion and palpation test ,and radiograph ranges from widened PDL to apical radio-lucency. Swelling of adjacent area is present and cervi-cal and submandibular lymph nodes usually tender to palpation.

TreatmentDrainage of abscess if localized, and RCT.

Chronic apical abscessPatient presented with sinus tract with pus discharge, with little or no pain. Vitality test report no response, and tooth usually not sensitive to biting test but feels different. Radiographically, apical radiolucency can be seen.

TreamtentRCT. Sinus tract will resolve after few days to months from endodontic treatment. If sinus tract is extraoral it will leave a scar.

Condensing ostietisThe tooth present with apical localized or diffuse apical radiopacity. The tooth could be vital or non-vital.

TreatmentIt depend on the condition of the pulp. If pulp is nor-mal then no treatment is required. If pulp is irreversibly inflammed then RCT is indicated. It should be noted that even with successful endodontic treatment some-times condesing ostietis does not resolve (according to a study 50% does not resolve). However, this can not present any problem to be concerned about.

REFERNCES

Endodontics principles and practice Cohens pathways of pulp