Published on February 26, 2014
DIAGNOSIS IN ENDODONTICS Fatima A. A.
Diagnosis “The science of recognizing disease by means of signs, symptoms and tests.” Effective treatments depends on an accurate diagnosis Two broad diagnostic scenarios: Emergency As part of a comprehensive treatment
Diagnostic Process Chief Complaint History: Medical & Dental Examination: Extra-oral & Oral Data Analysis Differential Diagnosis Treatment
Diagnostic Possibilities Pulpal Diagnosis Normal Reversible Pulpitis Irreversible Pulpitis Necrosis Periapical Diagnosis Normal Acute Apical Periodontitis Chronic Apical Periodontitis Acute Apical Abscess Chronic Apical Abscess Condensing Osteitis
Chief Complaint The first information obtained
Importance Volunteered by the patient In patient’s own words Patient will judge the outcome of the treatment according to how well it resolved the chief complaint Opportunity to capture patient’s confidence Capturing patient’s confidence facilitates education of the patient regarding diagnosis and treatment approach
Common Presenting Complaints Pain Swelling Broken tooth Loose tooth Tooth discoloration Bad taste
Pain “An unpleasant sensory and emotional experience associated with actual or potential tissue damage.” Most important and obvious complaint Types of Pain: Acute: Protective, arising from inflammation or injury to pulp and periapex Chronic: Non-protective, persists after or unrelated to injury Pain experience may be modulated by affective, motivational and cultural factors Peripheral and central changes after inflammation or injury may contribute to the development of hyperalgesia (increased response to painful stimulus), allodynia (pain provoked by normally non-painful stimulus), and spontaneous pain (unrelated to stimulus)
Pain System The “pain system” consists of: Nociceptors Small A C diameter nerve fibers fibers Fast-conducting, sharp pain fibers A Slow-conducting, dull throbbing pain fibers Not normally nociceptive but may be recruited due to central sensitization Tracts Central processing areas During pulpal inflammation, C fibers dominate
Central Sensitization Prolonged nociceptive input leads to functional changes in the subnucleus caudalis, the spinal dorsal horn, and the thalmus A major change is up-regulation of NMDA receptors on second-order neurons These changes produce hyperalgesia and widen the receptive fields Recruitment of normally non-pain fibers can produce allodynia Spontaneous activity occurs Widening of receptive fields and up-regulation of NMDA receptors enables convergence of input from multiple areas, leading to the referred pain phenomenon
Pain Referral Phenomenon Pain from one site is felt at another Convergence of neurons from other sites on a sensitized second-order neuron leads non-nociceptive levels of activity from these sites being misidentified as pain by higher centers of the pain system Referred pain never crosses the midline Common sites where pain may be referred from: Other teeth Muscles of mastication Sinuses/respiratory system Cardiac muscle Anesthetizing the true site of origin eliminates pain in referred sites Referred pain is a common occurrence
Endodontic Pain True origin is often silent May be referred, including to site of recent dental treatment Tooth pain may not be related to pulp condition Often poorly localized Periodontal pain is more easily located than pulpal pain Difficult to anesthetize inflamed pulp Patients have often used analgesics There may be multiple pain sources Different pain presentations may require different treatment strategies Stress and insomnia are often related to bruxism and temporomandibular disorder pain which can be referred to the pulp, complicating treatment with an amalgamation of psychogenic and organic factors
Non-Odontogenic Pain Origin Muscular Joint (Common) Underlying Disorder/Disease Myospasm Myositis Fibromyalgia Myofascial Pain Syndrome Temporomandibular Disorders Characteristics • Deep • Dull, aching • May be felt extra-orally near the ear, temple or on the face • Muscles of mastication most commonly affected • Depending on the location of the trigger point, the pain may progress from maxillary anteriors to premolars and then to maxillary molars Dull ‘Drilling’ ache Worsened by chewing or opening mouth Limited mouth opening Clicking sound Tenderness anterior to tragus of ear Deviation upon opening or dislocation of the jaws
Origin Neurologic Vascular (Common) Underlying Disorder/Disease Characteristics Trigeminal neuralgia Glossopharyngeal Neuralgia Post-herpetic neuralgia Trigeminal neuralgia: deep, lancinating, electrical paroxysmal pain classically lasting less than 2 min, triggered by light touch or chewing, following the course of the branches of fifth cranial nerve. Glossopharyngeal neuralgia: severe, jabbing pain in the pharynx and oral cavity parts supplied by ninth cranial nerve (tongue, throat, tonsils), triggered by chewing or swallowing. Post-herpetic neuralgia: burning or stabbing pain following an attack of herpes zoster. Migraine Giant Cell Arteritis Cluster headaches Neuralgia-inducing Cavitational Necrosis (neurovascular) Throbbing, burning pain Cluster headaches: pain may be deep, sudden, electric shock-like Pain follows the course of its vascular origin
Origin Inflammatory Neoplasms (Common) Underlying Disorder/Disease Characteristics Sinusitis Parotitis Otitis media Sinusitis: referral pain in maxillary teeth, facial pain, swelling and tenderness in the maxilla Parotitis: stringent, drawing pain Otitis media: pain may be referred to teeth and jaws. Osteosarcoma Chondrosarcoma Ewing’s Sarcoma Tumors are rarely painful. Most patients present with tooth mobility or other symptoms. Angina pectoris Manifestation of Systemic Myocardial Infarction Atypical odontalgia Disease/disorder (Psychogenic) Cardiogenic pain is typically described as a pressure or burning sensation, and may be left-sided and/or associated with chest pain. Psychogenic pain will persist despite absence of pathology, may be unresponsive to treatment, and are often associated with other psychiatric conditions such as anxiety disorders or somatization disorders.
Health History Clinical records to be reviewed during every visit
Preliminary Concerns Endodontic patients are generally older than average This population shows a higher and more complex incidence systemic medical problems Reduced response to treatment Treatment complicated by other factors such as bisphosphonate therapy
Antibiotic Prophylaxis Indications: Cardiac patients: Artificial heart valves History of infective endocarditis Congenital heart tissue defects and repairs Heart transplants Immunocompromised patients Hemophiliacs Insulin-dependent diabetics Patients who have had a joint replacement in the past 2 years Regimen Adults: 2 g amoxicillin 30-60 min pre-op Children: 50 mg/kg Penicillin-sensitive patients: clindamycin 600 mg 30-60 min pre-op
Dental History History of the Presenting Complaint: Onset Severity Duration Frequency Variation Aggravating factors Relieving factors Previous dental treatment (related and/or unrelated to presenting complaint)
Questions about Pain When did the pain begin? Where is he pain located? Is the pain always in the same place? Hat is the character of the pain? Does the pain prevent working or sleeping? Is the pain worse in the morning or evening? Is the pain worse when you lie down Did or does anything initiate the pain? Once initiated how long does the pain last Is the pain continuous, spontaneous or intermittent Does any thing make the pain worse Does anything make the pain better?
Questions about Swelling When did the swelling begin? How quickly has the selling increased in size Where is the swelling located What is the nature of the swelling Is there drainage from the swelling Is the swelling associated with the loose or tender tooth
Examination Collecting clinical evidence of pathology
Extra-Oral Examination • General appearance • Swelling • Scars • Skin tone • Discoloration • Sinus tracts • Facial asymmetry • Redness • Lymphadenopathy
Intra-oral Examination • Soft-tissue discoloration • Parulis • Tooth erosion • Inflammation • Intraoral swelling • Caries • Ulceration • Tooth fractures • Failing restorations • Sinus tracts • Tooth abrasion • Tooth discoloration
Diagnostic Aids Tests and Radiographs
Control Teeth Prior to performing any test, the clinician should select “control teeth” This calibrates the test and provides a baseline with which to compare the patient's response Control teeth should be similar to the suspect tooth As referred pain cannot cross the midlline, it may be preferable to select control teeth on the contralateral side The first application of the test is most significant
Percussion • • How: Use gentle digital pressure to detect exceptionally tender teeth that should NOT be percussed, then tap the occlusal or incisal surface of suitable with a mirror handle held parallel or perpendicular to the crown Result: Sharp pain indicates periapical inflammation; mild-to-moderate pain or pain restricted to tapping of facial surface is likely to be due to periodontal inflammation
Palpation • How: Apply firm pressure on the mucosa overlying the apex of the suspect tooth • Result: Pain indicates periapical inflammation
Cold Stimulation • • How: Dry and isolate the tooth, then apply an ice stick or large cotton pellet soaked with refrigerant Result: Intense, prolonged response indicates irreversible pulpitis; lack of response indicates necrotic pulp. False negative may occur in case of teeth with calcified canals (eg aged dentition) whereas false positive may occur if cold sensation is transferred to vital teeth or gingiva
Heat Stimulation • • How: It is best and safest to use a dry rubber prophy cup to produce frictional heat, after isolating the tooth with a rubber dam; alternatively, a syringe filled with hot water may be used Result: A sharp non-lingering response indicates vital (not necessarily normal) pulp
Electric Stimulation • • How: Clean, dry and isolate the tooth before applying a small amount of conducting medium/toothpaste on the electrode and placing it on the tooth; a lip clip or asking the patient to hold the metal handle completes the circuit Result: Absence of a response indicates necrosis; false negative may occur in case of calcified canals—margin of error is 10%-20%
Blood Flow Determination • • How: Sensors (dual wavelength spectrophotometer, pulse oximeter, or laser Doppler flowmeter) are applied to the facial and lingual surfaces to detect oxyhemoglobin levels in blood or pulsations in the pulp Result: Adequate perfusion indicates vital pulp with good healing potential
Dentin Stimulation • • How: When other tests are inconclusive, a small test cavity is made using a sharp bur without anesthesia Result: Sudden sensation of pain upon reaching dentin indicates vital pulp
Periodontal Examination • • How: Probing with a periodontal probe, followed by mobility testing using the index finger on the lingual surface while pressure is applied via a mirror handle on the facial surface Result: Periodontal health differentiates between periapical and periodontal lesions, and also acts as a prognostic indicator for root canal therapy
Radiographs • • How: Radiographs may be 2D or 3D and digital or traditional film-based; they all involve passing radiation through tissue Result: Apical loss of lamina dura, apical lucency that resembles a “hanging drop” and persists despite different cone angles, necrotic pulp, and radiopaque changes such as condensing osteitis indicate periapical lesion of endodontic origin
Additional Diagnostic Tests Caries removal Complete removal of soft caries (using a hand instrument) leading to exposure of pulp indicates irreversible pulpitis Selective anesthesia If a patient has difficulty localizing a painful tooth, mandibular block will confirm the region in case of mandible; a PDL injection delivered in an anterior to posterior sequence is more effective in the maxilla Transillumination Contrasting vertical and dark segments of the tooth are produced because fracture sites do not transmit light; teeth with longitudinal coronal fractures are also often tender to biting
Data Analysis & Differential Diagnosis “When you have eliminated the impossible, whatever remains, however improbable, must be the truth.” –Sherlock Holmes
Reaching a Diagnosis The diagnostic process should be followed in sequence to ensure systematic collection of data All data should be recorded and reviewed to give the clinician a detail-rich “whole picture” In most cases, the clinician should be able to list a number of differential diagnoses in order of likelihood Specific confirmatory tests may be undertaken to eliminate diagnoses from this list and arrive at a conclusive diagnosis In case of a strongly evidenced, highly likely provisional diagnosis it may be adequate to initiate treatment
Difficult Diagnosis A diagnosis is likely to be difficult if: Patient is unable to localize pain No local identifiable dental cause of pain Spontaneous or intermittent pain not necessarily elicited by a stimulus Non-reproducible symptoms Suspected tooth shows no clear etiology Multiple teeth involved Bilateral symptoms Selective anesthesia fails to localize pain source
Treatment Planning Last step of the diagnostic process, first step of the follow-up process
Choice of Treatment Both the course and ultimate success of the treatment follow the accuracy and comprehensiveness of the diagnosis In most cases, once an endodontic diagnosis is established, treatment is intracoronal (“conventional” or “non-surgical”) Surgical treatment is indicated when coronal access to the canal system is impossible
Procedure Difficulty The difficulty of surgical and non-surgical procedures should be assessed before undertaking the treatment If a patient has pain or swelling, emergency care should be provided even if ultimately the patient is to be referred to an endodontic specialist
Scheduling Single and multiple appointment therapies have the same success rate and same rate of post-therapy complication Most patients prefer single-appointment therapy Complex conditions require multiple appointments Time requirements should be discussed with the patient beforehand to plan a realistic, feasible schedule Patients with severe periapical symptoms or persistent canal exudation should be treated as quickly as possible, with none or minimal time between appointments to compensate for increased risk of flare-ups Flare-ups in such patients are considerably difficult to manage after canal obturation
References “Endodontics: Principles and Practice” by Mohamoud Torabinejad & Richard E. Walton, 4th edition “Differential Diagnosis of Toothache Pain” by Dr. Lisa Germain “Differential Diagnosis of Odontalgia” by College of Diplomates “A Note on Pulp Vitality Testing in Endodontics” by Upul Cooray
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