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Published on February 27, 2008

Author: Dorotea

Source: authorstream.com

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Diagnosis and Treatment Planning :  Diagnosis and Treatment Planning Definition:  Definition Diagnosis is the determination of the nature of a diseased condition by careful investigation of its symptoms and history Sequence of Events:  Sequence of Events Medical History Review Subjective History Objective Testing Analysis of data collected – Clinical diagnosis Plan of Action Medical History Review:  Medical History Review Review/update written medical questionnaire Medications Allergies Need for SBE prophylaxis Diabetes Pregnancy Written consultation with physician as required Medical History Review:  Medical History Review SBE Prophylaxis Required for endodontic treatment in at risk patients AHA recommendations should be followed Medical History Review:  Medical History Review Prescribe: 2 grams Amoxicillin 1 hour prior to treatment Clindamycin 600 mg for penicillin allergic patients Medical History Review:  Medical History Review Diabetes Do not treat uncontrolled diabetics Schedule appointment for early morning Ensure that patient has had morning insulin and breakfast Have a source of sugar readily available Medical History Review:  Medical History Review Pregnancy Avoid treatment in first and third trimesters Keep radiographic exposure to a minimum Medical History Review:  Medical History Review Latex Allergy Non-latex rubber dam Latex-free gloves One report of allergy to gutta-percha – no definitive proof that a true allergic reaction occurred Consult patient’s allergist Medical History Review:  Medical History Review The only systemic contraindications to endodontic therapy are: Uncontrolled diabetes A very recent myocardial infarct Subjective History:  Subjective History Chief complaint In patient’s own words “My tooth hurts when I chew hard foods” “I can’t drink cold soda” Pain History:  Pain History Subjective History:  Subjective History Pain History Location Intensity Duration Stimulus Relief Spontaneity Pulpal Pain:  Pulpal Pain Very poorly localized Intermittent Throbbing Intensified by heat, cold and sometimes chewing May be relieved by cold Usually severe Pulpal Pain:  Pulpal Pain Periradicular Pain:  Periradicular Pain May be well localized Deep pain Intensified by chewing Moderate to severe in intensity Periodontal Pain:  Periodontal Pain May be well localized Intensified by chewing Moderate to severe in intensity Periradicular /Periodontal Pain:  Periradicular /Periodontal Pain Subjective History:  Subjective History Gives rise to tentative diagnosis Determines urgency of treatment Confirmed by examination and special tests Objective Testing:  Objective Testing Visual Examination Radiographs Percussion Palpation Mobility Thermal tests Objective Testing:  Objective Testing Electric Pulp Test Periodontal probing Selective anesthesia Test cavity Transillumination Occlusion Visual Examination:  Visual Examination Extra-oral examination Facial asymmetry Swelling Extra oral sinus tract TMJ Extra-oral Swelling:  Extra-oral Swelling Visual Examination:  Visual Examination Extra oral sinus tracts associated with necrotic teeth Visual Examination:  Visual Examination Intra-oral examination Soft tissue lesions Swelling Redness Sinus tract Acute apical abscess:  Acute apical abscess Acute apical abscess Incision and drainage Visual Examination:  Visual Examination A sinus tract should be traced with a gutta-percha cone Visual Examination:  Visual Examination Hard tissues Caries Large or defective restorations Discolored/chipped teeth Discoloration:  Discoloration Radiographs:  Radiographs Always take your own pre-operative radiograph Never make a diagnosis based on radiographic evidence alone Radiographs:  Radiographs Consider taking a bitewing film of posterior teeth Note characteristic appearance of fractured root Radiographs:  Radiographs Characteristic J-shaped or halo lesion associated with fractured root Percussion Test:  Percussion Test A very significant test Always compare suspect tooth with adjacent and contralateral teeth Tenderness indicates inflammation in the PDL Cause of inflammation may be pulpal or periodontal Percussion Test:  Percussion Test Vertical percussion Horizontal percussion Percussion Test:  Percussion Test Tooth Slooth Used to assess cracked teeth and incomplete cuspal fractures Palpation Test:  Palpation Test Extraoral To detect swollen or tender lymph nodes Intraoral May detect early periapical tenderness Identifies soft tissue swelling Must compare with other areas Palpation:  Palpation Mobility:  Mobility Reflects the extent of inflammation in the PDL Compare with adjacent and contralateral teeth There are many causes of mobility besides pulpal inflammation extending into the PDL Thermal Tests:  Thermal Tests Cold always used Heat rarely used Compare reaction with adjacent and contralateral teeth Refractory period of at least 10 minutes before pulp can be retested accurately Thermal Tests:  Thermal Tests Thermal Tests:  Thermal Tests Ice stick CO2 Snow Thermal Tests:  Thermal Tests Isolate area with cotton rolls Dry teeth to be tested Ask patient to: “Raise hand on feeling cold” “Lower hand when cold feeling goes away” Record: + or – sensitivity to cold Time until cold sensitivity was felt Time that cold sensitivity lingered Thermal Tests:  Thermal Tests Classic Responses to Thermal (cold) Testing: Normal Pulp: Moderate transient pain Reversible Pulpitis: Sharp pain; subsides quickly Irreversible pulpitis: Pain lingers Necrosis: No response (Note false positive and false negative responses common) Electric Pulp Test:  Electric Pulp Test A direct test of nerve elements of pulpal tissue Vitality versus non-vitality only – not whether vital pulp is normal or inflamed In multi-rooted teeth, where one canal is vital – tooth usually tests vital False positives and false negatives may occur Electric Pulp Test:  Electric Pulp Test False positive reading: Electrode contact with metal restoration or gingiva Patient anxiety Liquefaction necrosis Failure to isolate and dry teeth prior to testing Electric Pulp Test:  Electric Pulp Test Electric Pulp Test:  Electric Pulp Test False negative reading: Patient is heavily premedicated Inadequate contact between electrode and enamel Recently traumatized tooth Recently erupted tooth with open apex Partial necrosis Electric Pulp Testing:  Electric Pulp Testing Periodontal Examination:  Periodontal Examination Periodontal probing pocket depths must be measured and recorded A significant pocket, in the absence of periodontal disease may indicate root fracture Poor periodontal prognosis may be a contraindication to root canal therapy Periodontal Examination:  Periodontal Examination Periodontal Examination:  Periodontal Examination An isolated deep pocket may indicate a root fracture Selective Anesthesia:  Selective Anesthesia May help to identify the possible source of pain An IDN block can localize pain to one arch Ability to anesthetize a single tooth has been questioned Test Cavity:  Test Cavity Initiation of cavity preparation without anesthesia Test of last resort Transillumination:  Transillumination Helps to identify vertical crown fracture Produces light and dark shadows at fracture site Transillumination:  Transillumination A crack will block and reflect the light when transilluminated Occlusion:  Occlusion Hyperocclusion – a possible cause of percussion sensitivity Analysis:  Analysis Analyze the data gathered via: History Examination Special tests Arrive at a clinical (not histologic) diagnosis: Pulpal diagnosis Periapical diagnosis Possible Pulpal Diagnoses:  Possible Pulpal Diagnoses Normal Reversible pulpitis Irreversible pulpitis Necrosis Previous endodontic treatment Normal Pulp:  Normal Pulp Symptoms None Radiograph No periapical change Pulp tests Responds normally Periapical tests Not tender to percussion or palpation Reversible Pulpitis:  Reversible Pulpitis Symptoms May have thermal sensitivity Radiograph No periapical change Pulp tests Responds – sensitivity not lingering Periapical tests Not tender to percussion or palpation Irreversible Pulpitis:  Irreversible Pulpitis Symptoms May have spontaneous pain Radiograph No periapical change Pulp Tests Pain that lingers Periapical tests Generally not tender to percussion or palpation Necrotic Pulp:  Necrotic Pulp Symptoms No thermal sensitivity Radiograph Dependent on periapical status Pulp tests No response Periapical tests Dependent on periapical status Possible Periapical Diagnoses:  Possible Periapical Diagnoses Normal Acute apical periodontitis Chronic apical periodontitis Chronic apical periodontitis with symptoms Acute apical abscess Chronic apical abscess Condensing osteitis Normal Periapex:  Normal Periapex Symptoms None Radiograph No periapical change Pulp tests Responds normally Periapical tests Not tender to percussion or palpation Acute Apical Periodontitis:  Acute Apical Periodontitis Symptoms Pain on pressure Radiograph No periapical change Pulp tests +/- depending on pulp status Periapical tests Tender to percussion and/or palpation High restorations, traumatic occlusion, orthodontic treatment, cracked teeth, vertical root fractures, periodontal disease and maxillary sinusitis may also produce this response Chronic Apical Periodontitis:  Chronic Apical Periodontitis Symptoms None Radiograph Periapical radiolucency Pulp tests No response Periapical tests Not tender to percussion or palpation Chronic Apical Periodontitis with symptoms:  Chronic Apical Periodontitis with symptoms Symptoms Pain on pressure Radiograph Periapical radiolucency Pulp tests No response Periapical tests Tender to percussion and/or palpation Acute Apical Abscess:  Acute Apical Abscess Symptoms Swelling and severe pain Radiograph +/- periapical radiolucency Pulp tests No response Periapical tests Tender to percussion and palpation Chronic apical abscess:  Chronic apical abscess Symptoms Draining sinus – usually no pain Radiograph Periapical radiolucency Pulp tests No response Periapical tests Not tender to percussion or palpation Condensing Osteitis:  Condensing Osteitis Symptoms Variable Radiograph Increased bone density Pulp tests Dependent on pulp status Periapical tests +/- tenderness to percussion and palpation Treatment Planning:  Treatment Planning Treatment decisions are based on: Pulpal diagnosis Periapical diagnosis Restorability of tooth Periodontal considerations Difficulty of case Financial considerations Treatment Planning:  Treatment Planning Two major decisions: Is root canal therapy indicated? Should I carry out this treatment myself or should I refer the case? Factors that add risk to Endodontic Cases:  Factors that add risk to Endodontic Cases Patient considerations Objective clinical findings Additional conditions Patient Considerations:  Patient Considerations Medical history Local anesthetic considerations Personal factors and general considerations Objective Clinical Findings:  Objective Clinical Findings Diagnosis Radiographic findings Pulpal space Root morphology Apical morphology Malpositioned teeth Additional Conditions:  Additional Conditions Restorability Existing restoration Fractured tooth Resorptions Endo-perio lesions Trauma Previous endodontic treatment Perforations AAE Case Difficulty Assessment Form:  AAE Case Difficulty Assessment Form Rate the risk presented by each factor as: Average – 1 High – 2 Extreme – 3 A case with all average ratings should be fairly straightforward AAE Case Difficulty Assessment Form:  AAE Case Difficulty Assessment Form AAE Case Difficulty Assessment Form:  AAE Case Difficulty Assessment Form If one or more factors present high or extreme risk, one must plan how to manage this extra risk prior to initiating treatment Presenting complaint :  Presenting complaint “ I had a crown placed about 6 years ago and now but I have a blister over that tooth” Dental History/History of presenting complaint:  Dental History/History of presenting complaint The patient reports no pain at any stage. She first noted the “blister” over tooth #14 about two weeks ago Medical History:  Medical History Allergy to penicillin Aspirin upsets pt’s stomach Subjective history:  Subjective history No subjective symptoms Pt reports presence of ‘blister’ on gum Examination:  Examination Extra-oral examination No facial asymmetry No cervical lymphadenopathy No muscle or joint tenderness Intra-oral examination Sinus present buccal to #14 Special tests:  Special tests Tooth #14 not tender on palpation Pus can be expressed from sinus tract No abnormal mobility Periodontal probing 6 mm on DP; in the 4 – 5 mm range elsewhere Special tests:  Special tests Pre-operative film:  Pre-operative film Diagnosis:  Diagnosis Pulpal necrosis Chronic apical abscess RCT and restoration Medical history does not affect treatment plan Access and Working length:  Access and Working length Completed RCT:  Completed RCT Summary :  Summary Pulpal Diagnoses Normal Reversible pulpitis Irreversible pulpitis Necrosis Summary:  Summary Periapical Diagnoses Normal Acute periradicular periodontitis Chronic periradicular periodontitis Acute apical abscess Chronic apical abscess Condensing osteitis Summary:  Summary To all intents and purposes a diagnosis of acute or chronic apical periodontits, acute or chronic apical abscess and condensing osteitis are associated with pulpal necrosis Summary:  Summary Treatment Planning Root canal therapy is indicated in situations in which the pulp cannot recover: Irreversible pulpitis Pulpal necrosis Summary:  Summary Following root canal therapy Posterior teeth must be restored with a crown. A post may be required if there is insufficient tooth structure to retain a core Anterior teeth may not require a full coverage restoration

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