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Principles of diagnosis in Endodontics

Diagnosis, pulpitis, perio-endo.

Treatment planning & case selection

Patients assessment Special tests which help us diagnose pulpal

disease How reliable are they?

Differential diagnosis of pulpal disease Aetiology of pulpal disease

Patient Assessment

• Medical history • Pain history • Extraoral examination • Intraoral examination

– Palpation – Percussion – Mobility – Periodontal examination – Fibreoptic light – Pulp testing

• Radiographic assessment

• where

• when, time of day/night

• duration, frequency

• character - patient’s own words

• intensity - pain scale

• aggravating factors

• alleviating factors

Pain History

Examination

Extraoral

Asymmetry

Facial swelling

Lymph nodes

Best viewed from above the patient

Examination

Intraoral

Soft tissue

OH

Periodontal condition

Incident of caries

Missing or unopposed teeth

Tooth wear, faceting

limited opening ?

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Examination

• TTP - inflammation of PDL

• TTpalp - inflammation of periosteum

• Mobility

• Sinus tract/s - trace with GP, if 2 suspect fracture

• Referred pain

Evaluate periodontal status

• attachment apparatus

• perio probing profile • Narrow vs broad pockets

• mobility

• periapical / bitewing

• crown to root ratio

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Special tests

• Electric pulp tester • Inflamed vs necrotic pulp

• Thermal – Heat ,GP, green stick, hot water

– Cold , ice sticks, ethyl chloride

• false +ve , false -ve • Local analgesia • Test cavity • Laser Doppler • imaging

Cold - Electrical

Imaging

• Digital

• Software - revealer

• CBCT

Radiological assessment and its limitation

• Assess size of the pulp chamber etc.

• Anatomical structures etc.

• Quality of existing root fillings etc.

• Assess condition of the periodontal tissues

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How to assess teeth?

• Restorability

• Crown down to apex

• 1/3 Rule (coronal 1/3, mid root 1/3, apical 1/3)

• Fractured instruments, blockages, ledges, missed canals, perforations, curvature

• Lesion, length, taper, voids, previously treated, coronal seal

Evaluate tooth restorability

Perio support

Strategic value of the tooth

Remaining tooth structure

Caries

Occlusal function

Common disorders revealed during endodontic assessment

• Concussed pulp

• Reversiable pulpitis

• Irreversiable pulpitis

• Pulpal necrosis

• Acute periapical inflammation

• Acute periapical abscess

• Chronic periapical periodontitis

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• Resorption:

– Internal

– external

• Fractured tooth

–Crown, root ( vital/non-vital)

–Horizontal, vertical fracture

• Atypical facial pain

American Association of Endodontists terminology

Pulpal Diagnosis

• Normal Pulp

• Reversible Pulpitis • exposed dentine, caries, deep restoration

• Symptomatic Irreversible Pulpitis • Sharp pain on thermal stimulus, ligers on, referred pain

• ? Pain on lying down, analgesics ? ineffective, spontaneity

• Asymptomatic Irreversible Pulpitis • No clinical symptoms, normal response to thermal

testing

• Pulp Necrosis • Asymptomatic, -ve response to thermal resting, cf none

infected/calcified pulp also –ve response to thermal testing

• Previously treated

• Previously initialed therapy

Apical Diagnosis

• Normal Apical Tissues

• Symptomatic Apical Periodontitis • +ve TTP, TTpalp, inflammation, +ve to biting

• Asymptomatic Apical Periodontitis • Apical radiolucency, no clinical symptoms

• Chronic Apical Abscess • Gradual onset, little or no discomfort, intermittent

discharge of pus through a sinus tract.

• Acute Apical Abscess • Rapid onset, spontaneous, +ve to pressure, pus &

swelling, ? Fever, lymphadenopathy, ?no radiolucency

• Condensing Osteitis • Diffused radiopaque lesion due to low-grade

inflammatory stimulus. The CO will regress following RCT.

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Aetiology of pulpal disease

Bacterial

• Mechanical

• Thermal

• Chemical

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Correlation between signs and symptoms and histological findings in pulpal disease

• Seltzer and Bender et al. (1963)

• Dummer et al. (1980)

Correlation between periodontal disease and endodontic lesion

• Seltzer and Bender (1963)

• Ehnevid (1993)

Cracked tooth syndrome

• Cameron (1976)

• Diagnosis

• Diagnostic aids

• Treatment

Tooth slooth

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Vertical root fracture

• Pitts (1983)

• Diagnosis

• Radiographic signs

• Treatment

Case selection

• Restorative consideration

• Periodontal consideration

• Sclerosis

• Resorption

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Treatment Planning

• Patients concerns • Expectations

• Motivation

• Cost

• Aim • Understanding the role of endodontics in restorative

treatment planning

Objectives

• Identifying and discussion of prognostic factors involved in endodontic treatment including RCT and Re-RCT

• Assessing teeth that require referral

• Discussing evidence available on outcome of endodontic treatment

• Examples of cases; simulated case treatment planning

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Restorative treatment plan • Emergency (endo)

• Primary disease – stabilisation of caries, periodontal, (endo)

• More advanced – (endo) , ortho, definitive perio, implant placement

• Even more advanced - final restorations, castings

Definition of Endodontology

• A branch of dental science concerned with study of form, function, health of, injuries to and disease of the dental pulp and periradicular region and their treatment.

What is Endodontic treatment?

• Pulp therapy

• RCT (non-surgical)

• Chemo-mechanical preparation

• Irrigants and medicaments

• Files

• Obturation

• Surgical

Aims of Endodontic

treatment?

• REMOVE

MICRO-ORGANISMS

Treatment options

• Re-RCT

• Endodontic surgery e.g. Root end surgery (Apisectomy), Root resection, hemisection ...

• Extraction

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Treatment options

• Extraction

• Leave gap

• Replace with

• Denture

• Bridge

• Implant

• Close with Orthodontics

Medico-legally

• Options

• Endo vs Extraction then

– Leave

– Denture

– Bridge

– Implant

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Perfect looking but still symptomatic?

• Previous treatment details; Rubber dam?

• You did it by the book, what can it be?

• What are the causes of failure?

Failure

• Infection

– Intracanal

– Extra-radiular

• Foreign body reaction

• Cyst

– True

– Bay

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Treatment options

• Re-RCT

• Surgery

• Extraction