Endodontic diagnosisRequirements of a diagnosticianClinical examinationsClinical endodontic tests.Factors influencing prognosis

Endo is a Greek word for "lnside" and Odont is Greek word for "Tooth" Endodontic

treatment treats inside of the tooth Endodontics is the branch of clinical dentistry associated

with the prevention, diagnosis and treatment of the pathosis of the dental pulp and peri-

radicular tissue. That is, the main aim of the endodontic therapy involves to:

1-Maintain vitalitY of the PulP'.

2-Preserve and restore the tooth with damaged and necrotic pulp.

3-Preserve and restore the teeth which have failed to the previous endodontic therapy' to allow the tooth to remain functional in the dental arch'

Background and aims:

Toothache resulting from infection of the dental pulp is a cause of severe suffering. The infection

often occurs as a result of:

1- dental caries.

2-Pulpal infections can also occur in non-carious teeth by cracks or fractures, due to external

trauma or in heavily restored teeth.

The purpose of root canal treatment by root filling of teeth (endodontics) is to prevent and treat

pulpal infections and thereby symptoms such as toothache and swelling because of suppuration, and for

functional and asymptomatic tooth, without signs of residual root canal infection, including loss of bone

at the root apex.

A. Set-up:

B. Charting: examination, diagnosis and treatment plan

1. Taking of medical history: Chief complaint, present illness, past medical

history, health form including medication, allergies and other relevant

information.

2. Examination; clinical and radiographical.

3. Diagnosis 4. Treatment plan, informed consent and cost of treatment.

C. Preparation of the tooth:

6. Preparative measures; pre-endodontic build-up, local anaesthesia,

access cavity preparation, rubber dam isolation.

D. Aseptic treatment:

7. Start locating and negotiating the rootcanal(s).

8. Decide working length with electronic apex locator.

9. Working length radiograph taken with a paralleling technique.

10. Radiographic verification or correction of working length.

11. Choose Reciproc-file.

12. Routine canal instrumentation.

13. Canal instrumentation deviant from normal routine.

14. Temporary canal dressing.

15. Master point radiograph.

16. Canal obturation E. Finalization procedures.

17. Coronal canal plug.

18. Coronal restoration, temporary or permanent.

19. Reflect upon and decicion of treatment prognosis.

F. Retreatment.

Examination and Diagnostic Procedures:

Endodontic diagnosis cannot be made from a single isolated piece of information. The clinician must

systematically gather all of the necessary information to make a “probable” diagnosis. When taking the

medical and dental history, the clinician should already be formulating in his or her mind a preliminary but

logical diagnosis, especially if there is a chief complaint. The clinical and radiographic examinations in

combination with a thorough periodontal evaluation and clinical testing (pulp and periapical tests) are then

used to confirm the preliminary diagnosis. Inspect extraorally for swellings or asymmetries; palpate the

lymph nodes.

A complete intraoral examination includes:

1-inspection.

2- palpation.

3- percussion and pulp sensibility tests.

Remember that pulp testing is a comparative test, so you need to test neighbouring as well as a

contralateral tooth to assess this patients normal response.

Electric pulp tester: Dry the teeth to be tested and maintain a dry working field. Place a dab of

toothpaste on the electrode tip, to enhance conductance. Place the probe incisally or on a cusp tip, well

away from any metal restorations or gum tissue. The current increases, indicated by the display, stop when

the patient can feel a sensation in the tooth and record the number on the display and what device and

scale that were used.

Cold testing is used alongside electric testing, but is well suited for teeth with large restorations that

block access with the electric probe. A cotton roll is held with a pair of pliers and one end is sprayed to

saturation with the test spray (Endo-Ice). Place the cotton roll end in firm contact with the buccal or lingual

surface of the tooth to be tested. Maintain a dry field; do not touch mucosa for prolonged periods. Record

reactions. The examination confirms which tooth that is to be treated, and is preceded by a preoperative or

starting radiograph, taken with a paralleling device. If a sinus tract is present, a separate radiograph is taken

with a gutta-percha point inserted in the tract.

In some cases, the clinical and radiographic examinations are inconclusive or give conflicting results and

as a result, definitive pulp and periapical diagnoses cannot be made.

It is also important to recognize that treatment should not be rendered without a diagnosis and in these

situations, the patient may have to wait and be reassessed at a later date or be referred to an endodontist.

The aim of pulp and root canal treatment is to prevent and treat pulpal infection. If the dentist

recommends treatment intended to preserve the pulp, the aim is that the tooth should be restored to a

healthy and functional state, and be free of symptoms such as shooting pain or toothache.

Volumetric tomography (CBCT: cone beam computer tomography) to be aware that the different

radiographic methods vary in their potential to depict minor alterations in bone tissue, which can be of

diagnostic importance.

In assessing pulpal condition, radiographic examination is often an important supplement to clinical

examination. It is particularly important to detect changes in the bone tissue around the root apex indicative of

a severely inflamed or infected pulp.

Radiographic examination is also used to evaluate the result of root canal therapy. In recent years

conventional film radiography has been superseded by digital radiography. A new method called CBCT (cone

beam computed tomography) or volume tomography has been developed.

Both digital and film radiography have limited ability to demonstrate small experimental areas of bone

destruction but good ability to identify normal conditions.

The new method CBCT is more sensitive and discloses more small areas of bone loss in comparison with

conventional radiographic techniques. Meanwhile there is insufficient documentation with respect to the

diagnostic accuracy of this method.

Toothache and hypersensitivity:

1- cold or heat stimulation and tenderness to percussion do not provide reliable information on the

condition of the pulp.

2-There is also an insufficient basis to allow assessment of the reliability of different tests for determining

whether the pulp is vital or not.

3-There is also an insufficient basis to both electrical and thermal tests as well as methods used to

determine the existence of pulpal blood circulation.

Diagnoses:

The art and science of detecting deviations from health and the cause and nature thereof, and determine

teeth free of disease rather than diseased.

Differential diagnosis:

The process of identifying a condition by comparing the symptoms of all (or other) pathologic process

that may produce signs and symptoms.

1-Medical and dental history:

-Medical and clarify medical history (Medical conditions, Medications).

2-Clinical examination:

-Review past dental experiences.

-Current concerns.

-subjective examination (Type of pain, Thermal sensitivity, Duration of pain).

-Objective examination (Intraoral tissues, Facial asymmetry, Swelling, Redness, Fistulas).

-Intraoral clinical examination (Tissues evaluated and palpated, Caries, Discoloration, Fractures).

-Clinical testing procedures:

.-Radiology (Radiolucent area on x-ray indicates bone involvement).

.-Palpation.

.-Precussion.

.-Mobility.

.-Cold test (Dry ice, ethylchloride, ice).

.-Heat test.

.-Pulp testing(Indicates if tooth vital or nonvital).

.-Transillumination test.

.-Selective anaesthesia.

.-Caries removal.

3-Refering dentist's notes.

Diagnoses:

Diagnostic method:

Pulpal Diagnoses:

Normal Pulp is a clinical diagnostic category in which the pulp is symptom-free and normally responsive to

pulp testing. Although the pulp may not be histologically normal, a “clinically” normal pulp results in a mild or

transient response to thermal cold testing, lasting no more than one to two seconds after the stimulus is

removed. One cannot arrive at a probable diagnosis without comparing the tooth in question with adjacent

and contralateral teeth. It is best to test the adjacent teeth and contralateral teeth first so that the patient is

familiar with the experience of a normal response to cold.

Reversible Pulpitis is based upon subjective and objective findings indicating that the inflammation should

resolve and the pulp return to normal following appropriate management of the etiology.

Discomfort is experienced when a stimulus such as cold or sweet is applied and goes away within a couple

of seconds following the removal of the stimulus. Typical etiologies may include exposed dentin (dentinal

sensitivity), caries or deep restorations. There are no significant radiographic changes in the periapical

region of the suspect tooth and the pain experienced is not spontaneous. Following the management of

the etiology (e.g. caries removal plus restoration; covering the exposed dentin), the tooth requires further

evaluation to determine whether the “reversible pulpitis” has returned to a normal status. Although

dentinal sensitivity per se is not an inflammatory process, all of the symptoms of this entity mimic those of a

reversible pulpitis.

Symptomatic Irreversible Pulpitis is based on subjective and objective findings that the vital inflamed pulp is

incapable of healing and that root canal treatment is indicated. Characteristics may include sharp pain upon

thermal stimulus, lingering pain (often 30 seconds or longer after stimulus removal), spontaneity

(unprovoked pain) and referred pain.

Sometimes the pain may be accentuated by postural changes such as lying down or bending over and over-the-

counter analgesics are typically ineffective. Common etiologies may include deep caries, extensive

restorations, or fractures exposing the pulpal tissues. Teeth with symptomatic irreversible pulpitis may be

difficult to diagnose because the inflammation has not yet reached the periapical tissues, thus resulting in no

pain or discomfort to percussion. In such cases, dental history and thermal testing are the primary tools for

assessing pulpal status.

Asymptomatic Irreversible Pulpitis is a clinical diagnosis based on subjective and objective findings indicating

that the vital inflamed pulp is incapable of healing and that root canal treatment is indicated. These cases have

no clinical symptoms and usually respond normally to thermal testing but may have had trauma or deep caries

that would likely result in exposure following removal.

Pulp Necrosis is a clinical diagnostic category indicating death of the dental pulp, necessitating root canal

treatment. The pulp is non-responsive to pulp testing and is asymptomatic. Pulp necrosis by itself does not

cause apical periodontitis (pain to percussion or radiographic evidence of osseous breakdown) unless the

canal is infected. Some teeth may be nonresponsive to pulp testing because of calcification, recent history

of trauma, or simply the tooth is just not responding. As stated previously, this is why all testing must be of

a comparative nature (e.g. patient may not respond to thermal testing on any teeth).

Previously Treated is a clinical diagnostic category indicating that the tooth has been endodontically treated

and the canals are obturated with various filling materials other than intracanal medicaments. The tooth

typically does not respond to thermal or electric pulp testing.

Previously Initiated Therapy is a clinical diagnostic category indicating that the tooth has been previously

treated by partial endodontic therapy such as pulpotomy or pulpectomy. Depending on the level of therapy,

the tooth may or may not respond to pulp testing modalities.

Apical Diagnoses:

Normal Apical Tissues are not sensitive to percussion or palpation testing and radiographically, the

lamina dura surrounding the root is intact and the periodontal ligament space is uniform. As with

pulp testing, comparative testing for percussion and palpation should always begin with normal

teeth as a baseline for the patient.

Symptomatic Apical Periodontitis represents inflammation, usually of the apical periodontium,

producing clinical symptoms involving a painful response to biting and/or percussion or palpation.

This may or may not be accompanied by radiographic changes (i.e. depending upon the stage of the

disease, there may be normal width of the periodontal ligament or there may be a periapical

radiolucency). Severe pain to percussion and/or palpation is highly indicative of a degenerating pulp

and root canal treatment is needed.

Asymptomatic Apical Periodontitis is inflammation and destruction of the apical periodontium that is

of pulpal origin. It appears as an apical radiolucency and does not present clinical symptoms (no pain

on percussion or palpation).

Chronic Apical Abscess is an inflammatory reaction to pulpal infection and necrosis characterized by gradual

onset, little or no discomfort and an intermittent discharge of pus through an associated sinus tract.

Radiographically, there are typically signs of osseous destruction such as a radiolucency. To identify the

source of a draining sinus tract when present, a guttapercha cone is carefully placed through the stoma or

opening until it stops and a radiograph is taken.

Acute Apical Abscess is an inflammatory reaction to pulpal infection and necrosis characterized by

rapid onset, spontaneous pain, extreme tenderness of the tooth to pressure, pus formation and

swelling of associated tissues. There may be no radiographic signs of destruction and the patient often

experiences malaise, fever and lymphadenopathy.

Condensing Osteitis is a diffuse radiopaque lesion representing a localized bony reaction to a low-

grade inflammatory stimulus usually seen at the apex of the tooth.

Diagnostic Case Examples:

Mandibular right first molar had been hypersensitive to cold and sweets over the past few months but the symptoms have subsided. Now there is no response to thermal testing and there is tenderness to biting and pain to percussion. Radiographically, there are diffuse radiopacities around the root apices. Diagnosis: Pulp necrosis; symptomatic apical periodontitis with condensing osteitis. Non-surgical endodontic treatment is indicated followed by a build-up and crown. Over time the condensing osteitis should regress partially or totally

Maxillary left first molar was endodontically treated more than 10 years ago.The patient is complaining of pain to biting over the past three months. There appear to be apical radiolucencies around all three roots. The tooth was tender to both percussion and to the Tooth Slooth®. Diagnosis: previously treated; symptomatic apical periodontitis. Treatment is nonsurgical endodontic retreatment followed by permanent restoration of the access cavity.

Maxillary left lateral incisor exhibits an apical radiolucency. There is no history of pain and the tooth is asymptomatic. There is no response to Endo-Ice® or to the EPT, whereas the adjacent teeth respond normally to both tests. There is no tenderness to percussion or palpation. Diagnosis: pulp necrosis; asymptomatic apical periodontitis. Treatment is nonsurgical endodontic treatment and placement of a permanent restoration.

Factors influencing prognosis in endodontic patients:

The key to success for endodontic treatment is thorough debridement of the root canal system of necrotic or

infected pulp tissues, microorganisms, and complete sealing of the root canal space. This will prevent the

persistence of infection and reinfection of the root canal space. The failure of endodontic treatment can be

determined on the basis of clinical signs and symptoms and radiographic findings of root canal treated tooth.

Periapical disease is an inflammatory response around root canal termini in response to intra-radicular

bacterial infection. It can be prevented (in the case of pulp inflammation) or resolved (in the case of pulp

infection) by root canal treatment. The endodontic failure is a common problem in dentistry. The success of

endodontic and re-endodontic treatment depends on many factors. These includes periodontal disease, root

fractures, residual necrotic pulp tissue, presence of per-radicular infection, broken instruments, mechanical

perforations, root canal under fillings, root canal overbillings, missed canals or unfilled canals, also

endodontic failures are more related with the lack of knowledge on the part of the operator, complex

anatomy of the teeth involved and lack of referral of such patients to the specialists.