Diagnosis TX Planning

Diagnosis & Diagnosis & Treatment Planning inTreatment Planning in

EndodonticsEndodontics

Dr Saidah TootlaDr Saidah Tootla

IntroductionIntroduction

EndodonticsEndodontics is the specialty of is the specialty of dentistry that manages the dentistry that manages the preventionprevention, , diagnosisdiagnosis, and , and treatmenttreatment of the dental pulp and of the dental pulp and the periradicular tissues that the periradicular tissues that surround the root of the toothsurround the root of the tooth

Causes of PulpitisCauses of Pulpitis

1.1. Physical irritationPhysical irritation – Most generally brought on by extensive Most generally brought on by extensive

decay.decay.

2.2. TraumaTrauma – Blow to a tooth or the jawBlow to a tooth or the jaw

3.3. AnachoresisAnachoresis

- retrograde infections- retrograde infections

Signs and SymptomsSigns and Symptoms

Pain when biting downPain when biting down Pain when chewing Pain when chewing Sensitivity with hot or cold beverages Sensitivity with hot or cold beverages Facial swelling Facial swelling Discolouration of the toothDiscolouration of the tooth

Endodontic DiagnosisEndodontic Diagnosis

Subjective examinationSubjective examination– Chief complaint Chief complaint – Character and duration of pain Character and duration of pain – Painful stimuli Painful stimuli – Sensitivity to biting and pressureSensitivity to biting and pressure– Discolouration of toothDiscolouration of tooth

Important questions?Important questions?

What do you think the problem is? What do you think the problem is? Does it hurt to hot or cold?  Does it hurt to hot or cold?  Does it hurt when you’re chewing? Does it hurt when you’re chewing? When does it start hurting? When does it start hurting? How bad is the pain?How bad is the pain? What type of pain is it? What type of pain is it? How long does the pain last?How long does the pain last? Does anything relieve it? Does anything relieve it? How long has it been hurting? How long has it been hurting?

Objective examinationObjective examination– Extent of decayExtent of decay – Periodontal conditions surrounding the Periodontal conditions surrounding the

tooth in questiontooth in question – Presence of an extensive restoration Presence of an extensive restoration – Tooth mobility Tooth mobility – Swelling or discoloration Swelling or discoloration – Pulp exposurePulp exposure

Challenges in diagnosis of pulpitisChallenges in diagnosis of pulpitis

Referred pain & the lack of proprioceptors in the pulp localizing the problem to the correct tooth can often be a considerable diagnostic challenge

Also of significance is the difficulty in relating the clinical status of a tooth to histopathology of the pulp in concern

Unfortunately, no reliable symptoms or tests consistently correlate the two.

Diagnostic TestsDiagnostic Tests

PercussionPercussion PalpationPalpation ThermalThermal ElectricalElectrical RadiographsRadiographs

1. Percussion tests1. Percussion tests

Used to determine whether the Used to determine whether the inflammatory process has extended inflammatory process has extended into the into the periapical tissuesperiapical tissues

Completed by the dentist tapping on the Completed by the dentist tapping on the incisal or occlusal surface of the tooth in incisal or occlusal surface of the tooth in question with the end of the mouth mirror question with the end of the mouth mirror handle held parallel to the long axis of the handle held parallel to the long axis of the toothtooth

– Used to determine whether the Used to determine whether the inflammatory process has extended into inflammatory process has extended into the the periapical tissuesperiapical tissues

– The dentist applies firm pressure to the The dentist applies firm pressure to the mucosa above the apex of the root mucosa above the apex of the root

2. Palpation tests2. Palpation tests2. Palpation tests2. Palpation tests

3. Thermal sensitivity3. Thermal sensitivity

Necrotic pulp will Necrotic pulp will notnot respond to cold respond to cold or hotor hot

1.1. Cold testCold test Ice, dry ice, or ethyl chloride used to Ice, dry ice, or ethyl chloride used to

determine the response of a tooth to determine the response of a tooth to coldcold

2.2. Heat testHeat test Piece of gutta-percha or instrument Piece of gutta-percha or instrument

handle heated and applied to the handle heated and applied to the facial surface of the toothfacial surface of the tooth

Evaluation of thermal test resultsEvaluation of thermal test results

4 distinct responses:4 distinct responses:

1.1. No responseNo response non-vital pulp non-vital pulp oror false false negativenegative

2.2. Mild responseMild response normal normal

3.3. Strong but briefStrong but brief reversible reversible

4.4. Strong but lingeringStrong but lingering irreversible irreversible

Causes of false Causes of false positives/negativepositives/negative

1.1. CalcifiedCalcified canals canals

2.2. Immature Immature apex – usually seen in apex – usually seen in young patientsyoung patients

3.3. TraumaTrauma

4.4. PremedicationPremedication of the patient – pulp of the patient – pulp sedatedsedated

4. Electric pulp testing4. Electric pulp testing

Delivers a small electrical stimulus to Delivers a small electrical stimulus to the the pulppulp

Factors that may influence readings:Factors that may influence readings:Teeth with extensive restorationsTeeth with extensive restorationsTeeth with more than Teeth with more than one canalone canal Dying pulp can produce a variety of Dying pulp can produce a variety of

responsesresponses Moisture on the tooth during testingMoisture on the tooth during testingBatteries in the tester may be weakBatteries in the tester may be weak

Placement of a pulp tester.Placement of a pulp tester.

5. Radiographs5. Radiographs

1.1. Pre-operative radiographPre-operative radiograph – Invaluable diagnostic toolInvaluable diagnostic tool– Periapical radiolucencyPeriapical radiolucency– Widening of PDLWidening of PDL– Deep cariesDeep caries– ResorptionResorption– Pulp stonesPulp stones– Large restorationsLarge restorations– Root fracturesRoot fractures

Requirements of Endodontic FilmsRequirements of Endodontic Films

Show 4-5 mm beyond the apex of the Show 4-5 mm beyond the apex of the tooth and the surrounding bone or tooth and the surrounding bone or pathologic condition.pathologic condition.

Present an accurate image of the Present an accurate image of the tooth without elongation or fore-tooth without elongation or fore-shortening.shortening.

Exhibit good contrast so all pertinent Exhibit good contrast so all pertinent structures are readily identifiable.structures are readily identifiable.

Quality radiograph in endodontics.Quality radiograph in endodontics.

Diagnostic ConclusionsDiagnostic Conclusions

1.1. Normal pulpNormal pulp

2.2. PulpitisPulpitis

Normal pulpNormal pulp

There are no subjective symptoms or There are no subjective symptoms or objective signs. The pulp responds objective signs. The pulp responds normally to sensory stimuli, and a normally to sensory stimuli, and a healthy layer of dentine surrounds the healthy layer of dentine surrounds the pulppulp

Pulpitis Pulpitis

The pulp tissues have become inflamedThe pulp tissues have become inflamed

Can be either:Can be either:

Acute Acute

– – inflammation of the periapical area inflammation of the periapical area

– – usually quite painfulusually quite painful

Chronic Chronic – Continuation of acute stage orContinuation of acute stage or– low grade infectionlow grade infection

Acute PulpitisAcute Pulpitis

mainly occurs in children teeth and mainly occurs in children teeth and adolescentadolescent

pain is more pronounced than in pain is more pronounced than in chronicchronic

Symptoms and SignsSymptoms and Signs of acute of acute pulpitispulpitis

The pain not localized in the affected tooth The pain not localized in the affected tooth is constant and throbbing worse by is constant and throbbing worse by reclining or lying downreclining or lying down

The tooth becomes painful The tooth becomes painful with hold or cold stimuliwith hold or cold stimuli The pain may be sharp and stabbingThe pain may be sharp and stabbing Change of color is obvious in the affected Change of color is obvious in the affected

toothtooth swelling of the gum or face in theswelling of the gum or face in the area of the affected tooth area of the affected tooth

Forms of acute pulpitisForms of acute pulpitis

1. Form of 1. Form of purulent acutepurulent acute where the where the pulp is totally inflamedpulp is totally inflamed

2. Form of 2. Form of gangrenous acutegangrenous acute where where the pulp begins to die in a less the pulp begins to die in a less painful manner that can lead into the painful manner that can lead into the formation of an abscessformation of an abscess

Chronic PulpitisChronic Pulpitis

1.1. ReversibleReversible

2.2. IrreversibleIrreversible

Reversible pulpitisReversible pulpitis

– The pulp is irritated, and the patient is The pulp is irritated, and the patient is experiencing pain to thermal stimuliexperiencing pain to thermal stimuli

– Sharp shooting painSharp shooting pain– Duration of the pain episode lasts for

seconds– The tooth pulp can be saved– Usually this condition is caused by

average caries

Irreversible pulpitisIrreversible pulpitis

– The tooth will display symptoms of lingering painThe tooth will display symptoms of lingering pain– pain occurs spontaneously or lingers minutes pain occurs spontaneously or lingers minutes

after the stimulus is removedafter the stimulus is removed– patient may have difficulty locating the tooth patient may have difficulty locating the tooth

from which the pain originatesfrom which the pain originates– As infection develops and extends through the As infection develops and extends through the

apical foramen, the tooth becomes exquisitely apical foramen, the tooth becomes exquisitely sensitive to pressure and percussionsensitive to pressure and percussion

– A periapical abscess elevates the tooth from its A periapical abscess elevates the tooth from its socket and feels “high” when the patient bites socket and feels “high” when the patient bites downdown

Periradicular abscessPeriradicular abscess

An inflammatory reaction to pulpal An inflammatory reaction to pulpal infection that can be chronic or have infection that can be chronic or have rapid onset with rapid onset with painpain, tenderness of the , tenderness of the tooth to tooth to palpationpalpation and and percussionpercussion, pus , pus formation, and formation, and swellingswelling of the tissues. of the tissues.

An inflammatory reaction frequently An inflammatory reaction frequently caused by bacteria entrapped in the caused by bacteria entrapped in the periodontal sulcus for a long time. A periodontal sulcus for a long time. A patient will experience rapid onset, patient will experience rapid onset, painpain, tenderness to , tenderness to palpationpalpation and and percussionpercussion, pus formation, and , pus formation, and swellingswelling..

Destruction of theDestruction of the

periodontium occursperiodontium occurs

Periodontal abscessPeriodontal abscessPeriodontal abscessPeriodontal abscess

Periradicular cystPeriradicular cyst

A cyst that develops at or near the root A cyst that develops at or near the root of a necrotic pulp. These types of cysts of a necrotic pulp. These types of cysts develop as an inflammatory response to develop as an inflammatory response to pulpal infection and necrosis of the pulppulpal infection and necrosis of the pulp

Pulp fibrosisPulp fibrosis

The decrease of living cells within the The decrease of living cells within the pulp causing fibrous tissue to take over pulp causing fibrous tissue to take over the pulpal canalthe pulpal canal

Necrotic toothNecrotic tooth

– Also referred to as Also referred to as non-vitalnon-vital.. Used to Used to describe a pulp that does not respond to describe a pulp that does not respond to sensory stimulussensory stimulus

– Tooth is usually discolouredTooth is usually discoloured

Plan of TreatmentPlan of Treatment

Depends widely on the diagnosisDepends widely on the diagnosis

Simple plan of treatmentSimple plan of treatment

Visit 1:Visit 1: Medical historyMedical history History of the toothHistory of the tooth Access cavityAccess cavity Place rubberdamPlace rubberdam Extirpation + irrigation with sodium hypochloriteExtirpation + irrigation with sodium hypochlorite Placed intra-canal medication (calcium hydroxide)Placed intra-canal medication (calcium hydroxide) Place cotton pelletPlace cotton pellet Placed temporary restoration (IRM/Kalzinol)Placed temporary restoration (IRM/Kalzinol)

Visit 2:Visit 2: Working length determinationWorking length determination Debridement using the hybrid techniqueDebridement using the hybrid technique IrrigationIrrigation Placed intra-canal medication (calcium Placed intra-canal medication (calcium

hydroxide)hydroxide) Place cotton pelletPlace cotton pellet Placed temporary restoration Placed temporary restoration

(IRM/Kalzinol)(IRM/Kalzinol)

Visit 3:Visit 3: Obturation with GP using lateral Obturation with GP using lateral

condensationcondensation

Placed temporary/permanent Placed temporary/permanent restoration (IRM/Kalzinol) restoration (IRM/Kalzinol)

ReferralReferral

To appropriate disciplineTo appropriate discipline

Remember Remember

Access cavity shapes:Access cavity shapes:1.1. Anterior – inverted triangleAnterior – inverted triangle2.2. Premolars – roundPremolars – round3.3. Molars – rhomboidMolars – rhomboid Always use rubberdamAlways use rubberdam Never to use Never to use CavitCavit as a temporary as a temporary

restorationrestoration Always place an intra-canal Always place an intra-canal

medication….calcium hydroxide???medication….calcium hydroxide??? Always use RC Prep or Glyde when filingAlways use RC Prep or Glyde when filing

Contraindications for RCTContraindications for RCT Caries extending beyond bone levelCaries extending beyond bone level Rubberdam cannot be placedRubberdam cannot be placed Crown of tooth cannot be restored in restorative Crown of tooth cannot be restored in restorative

dentistry nor prosthodonticsdentistry nor prosthodontics Patient is physically/mentally handicapped and Patient is physically/mentally handicapped and

therefore cannot follow OH instructionstherefore cannot follow OH instructions Putrid OHPutrid OH Unmotivated patientUnmotivated patient Severe root resorptionSevere root resorption Vertical root fracturesVertical root fractures Cost factorCost factor

Inter & cross-departmental Inter & cross-departmental diagnosisdiagnosis

Mobile teeth Mobile teeth Teeth associated with severe periodontal Teeth associated with severe periodontal

problemsproblems Confusion between TMJ dysfunctional Confusion between TMJ dysfunctional

symptoms and RCT painsymptoms and RCT pain Many decayed teethMany decayed teeth Sclerosed canal due to traumaSclerosed canal due to trauma Uncertainty of prognosis related to Uncertainty of prognosis related to

abscess, severe caries, facial swelling, abscess, severe caries, facial swelling, cellulites, and medical condition of patientcellulites, and medical condition of patient

Referral to post-grad clinicsReferral to post-grad clinics

Extensive internal or external root Extensive internal or external root resorptionresorption

Severely curved, narrow, tortuous Severely curved, narrow, tortuous canalscanals

Full-mouth rehabilitation requiredFull-mouth rehabilitation required Multiple exposures due to Multiple exposures due to

attrition/abrasion attrition/abrasion Problems with occlusion causing the Problems with occlusion causing the

need for RCTneed for RCT

Questions????Questions????