n Training in Basic Science enables: –Perform diagnostic tests –Interpret test results differentially –Psychologically manage patient during testing –Formulate diagnosis and treatment plan.
Systematic Approach to diagnosis 1. Ascertain chief complaint 2. Take relevant medical and dental history 3. Conduct thorough Subjective- Objective- Radiographic examinations 4. Analyze the data obtained 5. Formulate appropriate diagnosis
Scope of Endodontics n Vital Pulp therapy n Nonsurgical RCT n Endo Surgery n Retreatment n Hemisection-Root Amputation n Bleaching n Intentional replantation n Endodontic Endosseous implants n Apexification n Apexogenesis n Transplantation n Treatment of trauma n Perio-endo pathosis n Ortho-endodontics
Graduating General Dentist Should be very skilled in diagnosis and treatment planning over a broad base Should know when to consult and refer.
Systematic Approach to diagnosis 1. Ascertain chief complaint
Diagnosis 1. Chief Complaint –First information obtained –Problem expressed in patient’s own words –Recorded in non-technical language –If referred may be “No CC”
Diagnosis 1. Ascertain chief complaint 2. Take relevant medical and dental history
2. Health History –Comprehensive for new patients –Update data of prior patients n Demographic data n Medical History n Current Medications n Dental History n Chief complaint n Present illness
Demographic data n Identify Pt characteristics
Medical History n There are no absolute C/I to endodontics n Endodontics is less traumatic than extraction n Older patients are in need of RCT n Cases that need precautionary measures n When consultations are needed
Current Medications n List medications as presented by patient n Review C/I and precautionary measures
Dental History n Pay attention to state of patient n Ask probing questions n Establish good rapport and caring attitude.
Diagnosis 1. Ascertain chief complaint 2. Take relevant medical and dental history 3. Conduct thorough Subjective- Objective- Radiographic examinations
1.Subjective Examination n Present Illness n Pain n Tentative diagnosis
Present Illness n Only if a patient has a sign problem n If no sign symptoms go on to objective tests n Pain may affect pt;s psychology n Dr must be open, caring, and interested to elicit the most info n Ask further probing questions n Reiterate to the patient what they said in a clear manner.
Pain n Intensity –Intense irreversible pathosis –Recent, not long standing –Unrelieved by analgesic –Intermittent –Irreversible pulpitis –Acute apical periodontisits or abscess
n Spontaneous pain –Without eliciting stimulus –Awakens patient –May be relieved by cold –Usually irreversible pulpitis
n Continuous pain –Lingering type of pain after removal of stimulus –Continuous pain with thermal stimulus= irreversible pulpitis –Continuous pain after application of pressure = periradicular pathosis
Tentative diagnosis n Careful subjective questions n Rule out non-odontogenic causes n Urgency of treatment determined n Confirmed or denied by hands-on oral examination and clinical tests.
2.Objective Examination n Extraoral examination –General appearance –skin tone –Facial asymmetry –Swelling –Discoloration –Redness –Extraoral scars –Sinus tracts –Tender or enlarged lymph nodes
3.Radiographic examination n Periapical lesions (of odontogenic origin): –LD is lost apically –Angulation does not change position –Lucency resembles a hanging drop –Usually cause of necrosis is evident –Condensing ostietis- enostosis n Pulpal lesions
Special tests n Caries removal n Selective anesthesia n Transillumination n Sinus tract tracing
Diagnosis and Tx Plans n Normal or reversible pulpitis –Remove cause n Irreversible pulpitis –RCT n Necrosis
Treatment choices n Routine cases n Difficult Procedures –Complications –Adjunctive procedures n Prognosis
Systematic Approach to diagnosis 1. Ascertain chief complaint 2. Take relevant medical and dental history 3. Conduct thorough Subjective- Objective- Radiographic examinations 4. Analyze the data obtained
Diagnosissymptomsradiographicpulp testsPA testsTreatment Pulpal NormalNone Responds Not sensitive None (unless intentional)None Reversible Pulpitis may or may not have slight symptoms to theraml stimuliNo PA changesResponds Not sensitive None (unless intentional)Remove cause Irreversible Pulpitis may or may not have slight symptoms to thermal stimuli may have spontaneous or severe pain to thermal stimuli No PA changes condensing ostetis Responds may have severe pain on stimulus may or may not have pain on percussion and palpation RCT Pulpotomy, pulpectomy Extraction Necrosis None PA No responsePA RCT Extraction Periapical Normal None Responds Not sensitive None (unless intentional)None Acute Apical Periodontitis Pain on mastication or pressure NoneResponse No response Pain on percussion or palpation RCT Chronic apical periodontitis None mild Apical radiolucencyNo responseNone Mild pain on percussion or palpation RCT Acute Apical Abscess Swelling Significant pain Usually RL lesionNo responsePain on percussionDebridement Draining Chronic Apical abscess Draining sinusUsually RL lesionNo responseNoneRCT Condensing Osteitis variableIncrease bone density Variable
Difficult diagnosis n Longitudinal fratures n Cracked tooth n Stressed tooth
Treatment Planning n To treat or not to treat n Treatment related to diagnosis n Number of appointments
Prognosis n Assess difficulty of case n Refer when needed
422 RDS Clinical Endodontic Form Serial No.: __________ _________ Case No.: _________ Student's Name: File No.: Exam Date:________________ Patient's Name: Age: __________Sex: ______________Tooth No.: _______________ Telephone No.: (W)______________Chief Complaint: PAIN: CLINICAL EXAM: DIAGN OSTIC TESTS : THERAPY: None Swelling (intra/extraoral) Test ResultCaries control Vague Pain (soft/hard/fluctuant) Tooth Vital pulp therapy Pain to heat/cold Cellutitis Cold Apexification Pain to sweet/sour Sinus tract Hot Root canal therapy Pain to mastication Regional lymphadenopathy EPT Root canal retreatment Spontaneous/on stimulus Poor oral hygiene Percussion Surgical endodontics Intermitten/continuous Perio pocket ( mm) Palpation Extraction Localized/diffused/radiating Mobility (I/II/III) Test Cavity Others: Severe/moderate/mild Caries Probing Depth Duration: sec./mins./hrs. Restoration (minimal/large) Faculty Signature: Discoloration N = Normal MEDICAL ALERT:Crown fracture (class: ) AB = Abnormal Rheumatic fever Tooth (canal) already opened NR = No ResponseFaculty Comments: Rheumatic heart disease LR = Lingered Response High blood pressure RADIOGRAPHIC EXAM:NLR = Nonlingered Response Drug allergy ( ) Normal Hepatitis/tuberculosis Widen/thickened PDL DIAGNOSIS: Pregnancy Apical/lateral rarefaction a)Pulpal Others: Internal/external resorption Normal Caries Reversible pulpitis Start Check: REASON FOR TREATMENT:Calcification/pulp stone Irreversible pulpitis Date:Signature: Carious exposure Root fracture (H/V) Necrosis of pulp Mechanical exposure Furcation involvement Already Started Elective endo treatment Open apex b)Periapical Trauma Incomplete RCT Normal Perio Broken instrument Acute apical periodontitis Cracked tooth Perforation Chronic apical periodontitis Endo previously initiated Others: Acute apical abscess Overdenture Chronic apical abscess Others: Condensing osteitis
Name: Number of canals Points per canal Total Points for all canals Extra Procedure points Computer No.: ________________________ Total Points for case GUIDELINES FOR EVALUATION Procedures Session Signature -No instructor's permission/sign 0 + suspension No or improper Diagnosis-2.5 History, Examination, Diagnosis -No or improper RD isolationFailure/ -2.5 Patient management/LA -Improper patient management-2.5 Isolation -Ineffective LA-2.5 Access cavity N/A ACCESS Working length -Under-extended-1.5 Instumentation -Over-extended-2.5 Obturation -Improper location/gouging-3 Special Procedures -Perforation0 Special Procedures WL Knowledge -Improper size-3 Time Management -Under/over ext. >2mm-3 INSTRUM. MAC TOTAL GRADE [Faculty]: Signature: -Improper MAF-3 Course Director's Grade: -Apical perforation-3 -Stripping perforation0 FINAL GRADE [out of 10]: Signature: -Broken instrument0 -Flush-3 Root CanalRef. Point Int WLWLMAFMC -Not flared-3 SLSLSLSL OBTURATION -Short-3 -Over-extended GP-3 -Sealer ext. -Voids apically-3 -Voids middle/coronal-1.5 -Flush-2 Recall ExaminationPrognosis -No intermediate RG-3 -No final RG-3 Date FindingsGood -No final resto-5 ClinicalRadiographicPoor -Treating wrong tooth 0 + suspension Guarded -No medical history 0 + suspension Surgery Likely Comments: Faculty's Grade:
Sample Clinical Notes n 20 year old female patient n CC: “ I have a swelling and broken down tooth in my mouth” points to URQ n Med Hx: Juvenile Diabetes – controlled with medication (Insulin Injections 2X/day) n Dent Hx: Several extractions, fillings, and RCT
n Pain: in URQ started 2 weeks ago, wakes her up at night. Continuous, throbbing, is not relieved by analgesics, increases especially when drinking cold and pain continues after removal of the stimulus. n EOE: NAD n IOE: NAD tissues, large caries lesion in #16
n Tests: #16: –Pain on perc + palp –Severe lingering pain with Ice test (Endo frost) –Early response with EPT –No pockets –No mobiliy n Rad: small PA RL related to apex of #16
n Diag: Irreversible pulpitis with chronic PA periodontitis n Tx plan: RCT, P+C, PFM Crown
n Tx today: –IDNB 2% lidocaine – 2 carpules –Isolation –Caries excavation –Access –Filing and irrigation MB 19.5 mm 30 k DB 19.5 mm 30 k P 21 mm 40 k
n Dry canals n Cotton pellet n cavit
Reference n Principles & Practice of Endodontics 3 rd ed (2002) Walton & Torabinejad n Ch # 4
Homework 1. Write a table (or mind map) outlining medical conditions that may contraindicate or alter endodontic therapy 2. Outline clinical endodontic tests in a thorough, logical manner (tables or mindmaps can be used)
Next week’s lecture n Isolation n Radiography n Access Preparation & Length determination n Cleaning & Shaping n Obturation n Ch.8 n Ch. 9 n Ch. 12 n Ch. 13 n Ch. 14
Clinic n Attendance sheet will be removed after 15 mns n You will have 2 patients each to examine and fill out endo forms. n Your instructor will show you how to perform clinic tests for the whole group n Don’t forget to sign evaluation forms n Sign and dismiss 4:30 pm PROMPTLY