Diagnosis and treatment planning In Endodontic

Prof. Mohammad Salem Rekab

Damascus University-Syria

Faculty Of DentistryEndodontic Department

I -Introduction

Diagnosis and treatment planning are activities that separate and distinguish the dentist from auxiliary personnel.

II - Diagnosis

Diagnosis : Is the science of recognizing disease by means of signs , symptoms , and tests .

The chief complaint is generally the first information obtained. This is the problem expressed in the patient's own words about the condition that

prompted him or her to seek treatment ..

chief complaint

chief complaint

Chief complaint should be recorded as reported in nontechnical language; for example, "I have an infected tooth and a gum boil," or "I have a

toothache that may be causing my sinus problem".

chief complaint

When the patient is unaware of any problem or has been referred for diagnosis or treatment, these facts should also be recorded (as "no chief complaint") for future reference.

Health History

A complete health history for a new patient consists of : -routine demographic data-medical history-current medications history-chief complaint-and present illness

Demographic data identify the patient's characteristics

Demographic Data

A careful medical history not only aids diagnosis but also provides information about apatient's susceptibility andreactions to infection and

about bleeding, prescribedmedications, and emotional status.

Medical history

There are no specific medical conditions that contraindicate root canal treatment other than those that affect any dental procedure .

:These conditions include *irradiation of local tissues . *diseases that compromise the immune system, such as (AIDS)

*severe heart disease .

Other areas of concern that may :require special measures are

-the increasing incidence of latexallergies

-Hepatitis-delayed hemostasis

-certain cardiac conditions

Dental History

The dental history is a summary of present and past dental experiences . It provides valuable information about the patient's attitudes towardoral health, care, and treatment .

Present illnessFirst contact between patient and dentist takes place during collection of data about the present illness.

Subjective Examination

Most patients with endodontic pathoses are asymptomatic or have mild symptoms.

However some patients may have notable levels of pain and distress . These patients require a careful, systematic subjective examination with pointed, probing questions

such pain significantly alters emotional status.

Because of apprehension and emotional as well as occasional physical instability, endodontic patients are handled with

extra care.

An interesting and often confusing entity is tooth-related pain experienced with changes in ambient

pressure .

This phenomenon is known as barodontalgia and affects patients who

experience a pressure increase or decrease . It has been described in high-altitude flying and diving.

After listening with keen interest, the dentist should ask further questions about the severity, spontaneity, and duration of the pain and the stimuli that induce or relieve it .

Significant aspects of Pain some aspects of pain are strongly indicative of pulpal and/or periradicular pathosis and thus of the treatment required . These are the : (1) intensity (2) spontaneity (3) and persistence

IntensityThe more intense the pain (i.e., disruptive to a patient's lifestyle), the more likely it is that irreversible pathosis is present.

Intense pain is unrelieved by analgesics, and has prompted the patient to seek treatment.

Pain of a mild or moderate nature of long duration is not by itself, particularly diagnostic endodontically .

Intense pain may arise from irreversible pulpitis or from symptomatic (acute) apical periodontitis or abscess.

Spontaneous Pain Spontaneous pain occurs without stimulus. If pain awakens the patient or begins without stimulus, it is spontaneous. As described previously, spontaneous combined with intense pain usually indicates severe pulpal and/or periradicular pathosis.

Continuous Pain This lingering type of pain continues and may even increase in intensity after the stimulus is removed . For example, some patient reports prolonged pain after drinking cold liquids. Another describes intense continuous pain after chewing .

Continuous pain with thermal stimulus usually indicates irreversible pulpitis .

Continuous pain after application of pressure to a tooth indicates periradicular pathosis.

Tentative Diagnosis

By expanding on the present illness and asking careful subjective questions about the patient's problem, the dentist can often determine the presence or absence of pathologic changes in pulp or periapical.

Careful questioning and interpretation of the patient's responses often offer strong clues to a tentative diagnosis of pulpal or periradicular pathosis. The tentative diagnosis is then confirmed or denied by hands-on oral examination and clinical tests.

Objective examinationObjective examination

Extraoral examinationExtraoral examination includes:

General appearance, skin tone, facial asymmetry, swelling, discoloration, redness, extraoral scars or sinus tracts, and tender or enlarged facial or cervical lymph nodes are indicators of physical status.

Intraoral examination Intraoral examination includes :

visual and digital test of the oral soft tissues, and probing examination of the lips, oral mucosa, cheeks, tongue, palate, and muscles are evaluated and abnormalities are noted. Alveolar mucosa and attached gingiva are examined for the presence of discoloration, inflammation, ulceration, and sinus tract formation. Probing determines the presence of deep periodental defects.

1-soft tissue

2-Dentition

Teeth are examined for discolorations, fractures, abrasions, erosions, caries, large restorations, or

other abnormalities . A discolored crown is often pathognomonic of

pulpal pathosis .

Clinical tests

Clinical tests include use of a mirror and an explorer and periodontal probing as well as indicated pulpal and periapical tests.

“There is no easy resolution; patience and insight are required, and experience is helpful”

Mirror and explorer A mirror and an explorer reveal gross or recurrent caries, pulp exposures, crown fractures, defective restorations, and coronal leakage in teeth with previous root canal therapy.

In some instances (i.e., gross coronal decay), the mirror and explorer may provide sufficient information to arrive at a final diagnosis.

However, because pathologic changes usually cannot be determined by this method alone, other clinical tests are required.

Control teeth

These are healthy teeth that should respond normally. Control teeth have three functions:

(1) the patient learns what to expect from the stimulus.(2) the dentist can observe the nature of the patient's response to a certain level of stimulus.(3) the dentist can determine that the stimulus is capable of invoking a response.

Percussionpercussion may determine the presence of periradicular inflammation. This test is confirmatory if the patient reports pain upon mastication.

To establish a basis for comparison, the percussion test should also be performed on control teeth

Periapical tests

Percussion is performed by tapping on the incisal or occlusal surface with the end of a mirror handle held

parallel or perpendicular to the crown.

Another very good test is to have the patient bite hard on an object, such as a cotton swab

Palpation

palpation determines how far the inflammatory process has extended periapically. A positive response to palpation indicates periradicular inflammation.

Palpation is firm pressure on the mucosa overlying the apex .Pressure is applied by a finger tip and, like the percussion test, at least one control tooth should be included.

Direct denim stimulation, cold, heat, and electricity determine the response to stimuli and occasionally can identify the offending tooth by

an abnormal response . Response does not guarantee a pulp's viability or

health but at best indicates the presence of some nerve fibers carrying sensory impulses.

pulp vitality tests

The selection depends on the situation . Additional meaningful information is collected when stimuli similar to those that the patient reports will provoke pain are used

during clinical tests .

Selecting the appropriate pulp tester

Direct dentin stimulation

This is probably the most accurate and, in many cases, the best pulp vitality test .

Exposed dentin may be scratched with an explorer however, the absence of a response is not as indicative as

the presence of a response . When other tests are inconclusive or cannot be used and a necrotic pulp is suspected , a test cavity is helpful .

Cold testsThree methods are generally used for cold testing

regular ice

Refrigerant

carbon dioxide (dry ice)

False-negative response is often obtained when cold is applied to teeth with constricted canals (calcific metamorphosis).

False-positive response may result if cold water contacts gingiva or is transferred to adjacent teeth with vital pulps.

Heat tests Heat is not used routinely but is helpful when the major symptom is heat sensitivity, and the patient cannot identify the offending tooth .

Various techniques and materials are used.Gutta-percha is heated in a flame and applied to the facial surface.

The best, safest, and easiest technique is to rotate a dry rubber prophy cup to create frictional heat.

We can apply hot water

A mechanical, battery-powered device, such as the Touch-n-Heat, is better controlled and will deliver heat safely and effectively.

Significance of thermal tests

An exaggerated and lingering response is a good indication of irreversible pulpitis.

Absence of response in conjunction with other tests compared with results on control teeth usually

indicates pulpal necrosis.

electrical pulp testing Many devices are available commercially for electrical pulp tests.

The electrode is placed on the facial or lingual surface

The electrical pulp tester is not infallible and may produce false-positive or false-negative responses 10% to 20% of the time .

Warning

Response levels with different teethas shown by the number on thedevice do not indicate stages of pulpal

degeneration. .Electrical testers do not measure the degree of

health or disease of a pulp.

Blood flow determination

Instruments that detect pulp circulation are part of a developing technology that is likely to produce new approaches for determining the presence of vital pulp

tissue in an otherwise nonresponsive tooth .

Sensors are applied to the enamel surface, usually on both the facial and lingual surface. Blood now is shown by beams of light , (dual wavelength spectrophotometry), pulse oximetry,or laser Doppler flowmetry .

An example is the previously traumatized tooth that has an intact blood supply, but no intact sensory nerves and therefore is unresponsive to stimuli. These very sensitive devices will detect pulp blood components or blood flow in these situations.

Probing

A periodontal probe determines the level of connective tissue attachment .

Also, the probe penetrates into an inflammatory periapical lesion that extends cervically .

Periodontal examination

The prognosis for a tooth with a necroric pulp that induces cervically extending periapical inflammation is good after adequate root canal treatment.

However, the outcome of root canal

treatment on a tooth with severe periodontal disease usually depends on the success of

periodontal treatment .

Mobility

The mobility test partially determines the status of both the periodontal ligament and prognosis.

Movement of more than 2 to 3 mm indicates that the tooth is a poor candidate for root canal treatment if the mobility is due primarily to periodontal disease and not to periradicular pathosis.

Mobility is determined by placing the index finger on the lingual aspect and applying pressure with the mirror handle on the opposite facial surface .

Radiographs allow evaluation of *tooth-related problems (e.g.; carious lesions, defective

restorations, and root canal treatments.(*abnormal pulpal and periradicuiar appearances.

*malpositioned teeth.*relationship of the neurovascular bundle to the apexes.

the general bony pattern.* *periodontal disease.

Radiographic examination

Periapical lesions

* The lamina dura is lost apically. * The lucency remains at the apex regardless of

the cone angle .* The lucency tends to resemble a hanging drop.* usually a cause of the pulp necrosis is evident .

 

Pulpal lesions

Few specific pathologic entities that relate to irreversible pulpitis are visible radiographically .

An inflamed pulp with dentinoclastic activity may show abnormally altered pulp space enlargement and is pathognomonic of internal resorption .

Extensive diffuse calcification in the chamber may indicate long term, low grade Irritation (not necessarily of irreversible pulpitis).

Dentin formation that radiographically "obliterates" the canals (usually in patients with a history of trauma) does not in itself indicate pathosis.

These teeth ordinarily require no treatment but when treatment is necessary, they can be managed with reasonable success.

Caries removal In the cases of deep caries on radiographs, no significant history or presenting symptoms, and a pulp that responds to clinical tests .

All other findings are normal. The final definitive test is complete caries removal to establish pulp status.

Additional Diagnostic Procedures

Selective Anesthesia

The selective anesthesia test is usefull in painful teeth, particularly when the patient cannot isolate the offending tooth even to a specific arch.

If a mandibular tooth is suspected, a mandibular block will confirm at least the region if the pain disappears after the injection.

Because an inferior alveolar nerve block anesthetizes all teeth in the quadrant, selective anesthesia is not useful for the mandible.

Individual tooth anesthesia is most effective in the maxilla .

Anesthetic should be administered in an anterior to posterior direction because of

the distribution of the sensory nerves.

Transillumination This test helps to identify longitudinal crown fractures .

Difficult diagnosis

Some perplexing conditions defy diagnosis even after thorough subjective, objective, and

radiographic examinations . Usually these situations do not require immediate treatment and the patient may be scheduled for a return visit for further evaluation or possibly

dental and medical consultation .

Diagnostic Findings and Terminology

Use of a data form to accumulate diagnostic findings serves three purposes:

1-it ensures that all pertinent information has been assessed and included.

2-it ensures that findings have been recorded and may be analyzed .

3-it allows future reference to findings noted at the initial appointment .

The findings are arranged in a rational order to arrive at a pulpal or periradicular diagnosis.

III - Treatment planning

To treat or not to treat

A common question is "But doctor, it doesn't hurt .Is it necessary to do this at all, or can't we just wait

and see if it does bother me "?

The explanation of the necessity for immediate treatment is that progressive disease(pulp and/or periapical) is present, and early management enhances the chances for

successful treatment .

A good explanation to the asymptomatic patient is that this problem is a time bomb

ticking away .The problem is that we cannot know when it will go off, but it probably will do so at an

inopportune time.

Treatment related to diagnosis

The pulpal diagnosis in general dictates the approach, reversible pulpitis may or may not require noninvasive treatment.

But irreversible pulpitis require extraction or root canal treatment or at least removal of the inflamed portion of the pulp with pulpotomy or partial pulpectomy.

Number of appointments

Most investigations indicate that, in general, single-appointment root canal treatment is acceptable.

However, the general dentist should approach this type of treatment with caution and careful patients

selection .

There are situations that require more than a single appointment:

One is the condition that is complex or time consuming. Related to this and most important is patient management and the tolerance level of

patient and operator.

Multiple appointments

A second situation is the patient with severe periradicular symptoms or persistent canal

exudation .These are often emergencies, and the tolerance level of the patient is low

A third indication may be a diagnosis of pulp necrosis and asymptotic apical

pathosis.

There is some preliminary evidence (not conclusive) that healing may be better if there are two visits and calcium hydroxide is placed

as an intracanal medicament.

when conclude appointment?

The questions to be answered are as follows: *What should be completed to minimize

interappointment problems ?*what point may a temporary filling be placed?

Effects on prognosis and pain

Most studies indicate that in the asymptomatic patient, post-treatment pain is unrelated to whether treatment is completed in single or

multiple appointments.

Single-appointment root canal treatment should always be approached with some caution and with consideration of each

individual case.

Normal Pulp and reversible Pulpitis

Root canal treatment is not indicated (unless elective) .

In patients with reversible pulpitis, the cause is usually removed and restoration follows (if necessary).

Pulpitis

Specific Treatmeants

Irreversible Pulpitis

Root canal treatment, pulpotomy, partial pulpectomy, or extraction isrequired. ultimately total pulp removal is preferredif circumstances do not permit complete pulpectomy, pulpotomy or partial pulpectomy is acceptable.

Root canal treatment is indicated when necrosis is present.

Necrosis

No special treatment approach is required .

periradicular diagnosis

Normal

Symptomatic (Acute) apical periodontitis

It is critical to remove the inflamed pulp or necrotic tissue with a diagnosis of symptomatic apical periodontitis. With the cause of the disease process removed, itwill resolve.

Asymptomatic (Chronic) apical periodontitis

Treatment for asymptomatic apical periodontitis is thesame as that for acute apical periodontitis. The size of thelesion seen on radiograph is of little concern, Lesions ofdifferent sizes will heal after appropriate treatment.

Debridement Most critical is debridement of irritants from the canal space; therefore, complete or nearly complete cleaning and shaping with copious, careful irrigation are desired.

Drainage Next in importance is drainage through

the tooth or soft tissue.

Acute Apical abscess

Chronic Apical abscessor

Suppurative apical periodontitis

Because this lesion is asymptomatic owing to intraoral or extraoral drainage of an abscess, no special treatment measures are

necessary .

Again, the key is debridement; the tract or parulis should resolve spontaneously once

irritants from the pulp space are removed . A persistent draining sinus tract indicates a misdiagnosis (is it a periodontal abscess?), a missed canal, or in adequate debridement

or obturation .

Routine cases Most uncomplicated root canal treatment procedures can and should be done by the general practitioner .The most important point is to identify the routine

nature of each case and plan accordingly .

Treatment choices

Difficult procedures Managing difficulties depends on the knowledge

and skills of the general practitioner . Equally important is access to the appropriate

instruments and materials . The decision to treat or refer is based on the individual patient case and not on a

predetermined set of criteria.

Treatment ModifiersComplications

Conditions that may require modifications include : severe caries, failed root canal treatment, operative problems, isolation difficulties, abnormal root or pulp anatomy,medical complications,and calcifications.

Any one or a combination of these may designate a patient with a complex problem that should be considered for consultation or referral.

IV -Prognosis

The practitioner should calculate a prognosis for each situation, including a contingency prognosis if problems are encountered after treatment has begun.

Thus, to provide the best treatment, the generalist and specialist must communicate, share treatment problems, and exchange ideas for providing the best treatment for their patients.