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Diagnosis and Treatment Planning. Definition Diagnosis is the determination of the nature of a diseased condition by careful investigation of its symptoms.

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Presentation on theme: "Diagnosis and Treatment Planning. Definition Diagnosis is the determination of the nature of a diseased condition by careful investigation of its symptoms."— Presentation transcript:

1 Diagnosis and Treatment Planning

2 Definition Diagnosis is the determination of the nature of a diseased condition by careful investigation of its symptoms and history

3 Sequence of Events Medical History Review Subjective History Objective Testing Analysis of data collected – Clinical diagnosis Plan of Action

4 Medical History Review Review/update written medical questionnaire Medications Allergies Need for SBE prophylaxis Diabetes Pregnancy Written consultation with physician as required

5 Medical History Review SBE Prophylaxis Required for endodontic treatment in at risk patients AHA recommendations should be followed

6 Medical History Review Prescribe : 2 grams Amoxicillin 1 hour prior to treatment Clindamycin 600 mg for penicillin allergic patients

7 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

8 Medical History Review Pregnancy Avoid treatment in first and third trimesters Keep radiographic exposure to a minimum

9 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 patients allergist

10 Medical History Review The only systemic contraindications to endodontic therapy are: Uncontrolled diabetes A very recent myocardial infarct

11 Subjective History Chief complaint In patients own words My tooth hurts when I chew hard foods I cant drink cold soda

12 Pain History

13 Subjective History Pain History Location Intensity Duration Stimulus Relief Spontaneity

14 Pulpal Pain Very poorly localized Intermittent Throbbing Intensified by heat, cold and sometimes chewing May be relieved by cold Usually severe

15 Pulpal Pain

16 Periradicular Pain May be well localized Deep pain Intensified by chewing Moderate to severe in intensity

17 Periodontal Pain May be well localized Intensified by chewing Moderate to severe in intensity

18 Periradicular /Periodontal Pain

19 Subjective History Gives rise to tentative diagnosis Determines urgency of treatment Confirmed by examination and special tests

20 Objective Testing Visual Examination Radiographs Percussion Palpation Mobility Thermal tests

21 Objective Testing Electric Pulp Test Periodontal probing Selective anesthesia Test cavity Transillumination Occlusion

22 Visual Examination Extra-oral examination Facial asymmetry Swelling Extra oral sinus tract TMJ

23 Extra-oral Swelling

24 Visual Examination Extra oral sinus tracts associated with necrotic teeth

25 Visual Examination Intra-oral examination Soft tissue lesions Swelling Redness Sinus tract

26 Acute apical abscess Incision and drainage

27 Visual Examination A sinus tract should be traced with a gutta-percha cone

28 Visual Examination Hard tissues Caries Large or defective restorations Discolored/chipped teeth

29 Discoloration

30 Radiographs Always take your own pre-operative radiograph Never make a diagnosis based on radiographic evidence alone

31 Radiographs Consider taking a bitewing film of posterior teeth Note characteristic appearance of fractured root

32 Radiographs Characteristic J-shaped or halo lesion associated with fractured root

33 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

34 Percussion Test Vertical percussionHorizontal percussion

35 Percussion Test Tooth Slooth Used to assess cracked teeth and incomplete cuspal fractures

36 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

37 Palpation

38 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

39 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

40 Thermal Tests

41 Ice stick CO2 Snow

42 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

43 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)

44 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

45 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

46 Electric Pulp Test

47 False negative reading : Patient is heavily premedicated Inadequate contact between electrode and enamel Recently traumatized tooth Recently erupted tooth with open apex Partial necrosis

48 Electric Pulp Testing

49 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

50 Periodontal Examination

51 An isolated deep pocket may indicate a root fracture

52 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

53 Test Cavity Initiation of cavity preparation without anesthesia Test of last resort

54 Transillumination Helps to identify vertical crown fracture Produces light and dark shadows at fracture site

55 Transillumination A crack will block and reflect the light when transilluminated

56 Occlusion Hyperocclusion – a possible cause of percussion sensitivity

57 Analysis Analyze the data gathered via: History Examination Special tests Arrive at a clinical (not histologic) diagnosis: Pulpal diagnosis Periapical diagnosis

58 Possible Pulpal Diagnoses Normal Reversible pulpitis Irreversible pulpitis Necrosis Previous endodontic treatment

59 Normal Pulp SymptomsNone RadiographNo periapical change Pulp testsResponds normally Periapical testsNot tender to percussion or palpation

60 Reversible Pulpitis SymptomsMay have thermal sensitivity RadiographNo periapical change Pulp testsResponds – sensitivity not lingering Periapical testsNot tender to percussion or palpation

61 Irreversible Pulpitis SymptomsMay have spontaneous pain RadiographNo periapical change Pulp TestsPain that lingers Periapical testsGenerally not tender to percussion or palpation

62 Necrotic Pulp SymptomsNo thermal sensitivity Radiograph Dependent on periapical status Pulp testsNo response Periapical testsDependent on periapical status

63 Possible Periapical Diagnoses Normal Acute apical periodontitis Chronic apical periodontitis Chronic apical periodontitis with symptoms Acute apical abscess Chronic apical abscess Condensing osteitis

64 Normal Periapex SymptomsNone RadiographNo periapical change Pulp tests Responds normally Periapical testsNot tender to percussion or palpation

65 Acute Apical Periodontitis SymptomsPain on pressure RadiographNo periapical change Pulp tests+/- depending on pulp status Periapical testsTender 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

66 Chronic Apical Periodontitis SymptomsNone RadiographPeriapical radiolucency Pulp testsNo response Periapical testsNot tender to percussion or palpation

67 Chronic Apical Periodontitis with symptoms SymptomsPain on pressure RadiographPeriapical radiolucency Pulp testsNo response Periapical testsTender to percussion and/or palpation

68 Acute Apical Abscess SymptomsSwelling and severe pain Radiograph+/- periapical radiolucency Pulp testsNo response Periapical testsTender to percussion and palpation

69 Chronic apical abscess SymptomsDraining sinus – usually no pain RadiographPeriapical radiolucency Pulp testsNo response Periapical testsNot tender to percussion or palpation

70 Condensing Osteitis SymptomsVariable RadiographIncreased bone density Pulp testsDependent on pulp status Periapical tests+/- tenderness to percussion and palpation

71 Treatment Planning Treatment decisions are based on: Pulpal diagnosis Periapical diagnosis Restorability of tooth Periodontal considerations Difficulty of case Financial considerations

72 Treatment Planning Two major decisions: Is root canal therapy indicated? Should I carry out this treatment myself or should I refer the case?

73 Factors that add risk to Endodontic Cases Patient considerations Objective clinical findings Additional conditions

74 Patient Considerations Medical history Local anesthetic considerations Personal factors and general considerations

75 Objective Clinical Findings Diagnosis Radiographic findings Pulpal space Root morphology Apical morphology Malpositioned teeth

76 Additional Conditions Restorability Existing restoration Fractured tooth Resorptions Endo-perio lesions Trauma Previous endodontic treatment Perforations

77 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

78 AAE Case Difficulty Assessment Form

79 If one or more factors present high or extreme risk, one must plan how to manage this extra risk prior to initiating treatment

80 Presenting complaint I had a crown placed about 6 years ago and now but I have a blister over that tooth

81 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

82 Medical History Allergy to penicillin Aspirin upsets pts stomach

83 Subjective history No subjective symptoms Pt reports presence of blister on gum

84 Examination Extra-oral examination No facial asymmetry No cervical lymphadenopathy No muscle or joint tenderness Intra-oral examination Sinus present buccal to #14

85 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

86 Special tests Tooth #1314153 PercussionNegative ThermalNormalNo response Normal EPT56No response Not possible to test 49

87 Pre-operative film

88 Diagnosis Pulpal necrosis Chronic apical abscess RCT and restoration Medical history does not affect treatment plan

89 Access and Working length

90 Completed RCT

91 Summary Pulpal Diagnoses Normal Reversible pulpitis Irreversible pulpitis Necrosis

92 Summary Periapical Diagnoses Normal Acute periradicular periodontitis Chronic periradicular periodontitis Acute apical abscess Chronic apical abscess Condensing osteitis

93 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

94 Summary Treatment Planning Root canal therapy is indicated in situations in which the pulp cannot recover: Irreversible pulpitis Pulpal necrosis

95 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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