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 Pain History where when, time of day/night duration, frequency character - patient s own words intensity - pain scale aggravating factors alleviating factors 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? 1
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 2
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 Digital Software - revealer CBCT Imaging 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 3
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 4
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. 5
Aetiology of pulpal disease Bacterial Mechanical Thermal Chemical 6
Correlation between signs and symptoms and histological findings in pulpal disease Correlation between periodontal disease and endodontic lesion Seltzer and Bender et al. (1963) Dummer et al. (1980) Seltzer and Bender (1963) Ehnevid (1993) Cracked tooth syndrome Tooth slooth Cameron (1976) Diagnosis Diagnostic aids Treatment 7
Vertical root fracture Pitts (1983) Diagnosis Radiographic signs Treatment Case selection Restorative consideration Periodontal consideration Sclerosis Resorption 8
Treatment Planning Objectives Patients concerns Expectations Motivation Cost Aim Understanding the role of endodontics in restorative treatment planning 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 9
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 10
Treatment options Extraction Leave gap Replace with Denture Bridge Implant Close with Orthodontics Medico-legally Options Endo vs Extraction then Leave Denture Bridge Implant 11
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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 13
Treatment options Re-RCT Surgery Extraction 14