Presentation is loading. Please wait.

Presentation is loading. Please wait.

Clinical Diagnostic Procedures Ch #4 Diagnosis & Tx Planning.

Similar presentations


Presentation on theme: "Clinical Diagnostic Procedures Ch #4 Diagnosis & Tx Planning."— Presentation transcript:

1 Clinical Diagnostic Procedures Ch #4 Diagnosis & Tx Planning

2 n Training in Basic Science enables: –Perform diagnostic tests –Interpret test results differentially –Psychologically manage patient during testing –Formulate diagnosis and treatment plan.

3 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

4 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

5 Graduating General Dentist Should be very skilled in diagnosis and treatment planning over a broad base Should know when to consult and refer.

6 Systematic Approach to diagnosis 1. Ascertain chief complaint

7 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”

8 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September :24 PM) © 2005 Elsevier

9 Diagnosis 1. Ascertain chief complaint 2. Take relevant medical and dental history

10 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

11 Demographic data n Identify Pt characteristics

12 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

13 Current Medications n List medications as presented by patient n Review C/I and precautionary measures

14 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September :24 PM) © 2005 Elsevier

15 Dental History n Pay attention to state of patient n Ask probing questions n Establish good rapport and caring attitude.

16 Diagnosis 1. Ascertain chief complaint 2. Take relevant medical and dental history 3. Conduct thorough Subjective- Objective- Radiographic examinations

17 1.Subjective Examination n Present Illness n Pain n Tentative diagnosis

18 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.

19 Pain n Intensity –Intense irreversible pathosis –Recent, not long standing –Unrelieved by analgesic –Intermittent –Irreversible pulpitis –Acute apical periodontisits or abscess

20 n Spontaneous pain –Without eliciting stimulus –Awakens patient –May be relieved by cold –Usually irreversible pulpitis

21 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

22 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.

23 2.Objective Examination n Extraoral examination –General appearance –skin tone –Facial asymmetry –Swelling –Discoloration –Redness –Extraoral scars –Sinus tracts –Tender or enlarged lymph nodes

24 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September :24 PM) © 2005 Elsevier

25 n Intraoral examination –Soft tissue: n Lips-Oral mucosa- Cheeks- Tongue- Palate- Muscles –Alveolar mucosa & attached gingiva n Discoloration n Inflammation n Ulceration n Sinus tract formation

26 –Dentition n Discoloration n Fractures n Abrasions n Erosions n Caries n Large restorations

27 Clinical tests n Complex Process n Tests of patients response! n Presence of limitations n May be inconclusive n Supplementary confirmatory tests needed n False-neg + False-pos n Control teeth

28 Periapical tests n Percussion n Palpation –Indicative of periradicular inflamation

29 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September :24 PM) © 2005 Elsevier

30 Pulp vitality tests n Cold tests n Direct dentin stimulation n Heat tests n Electric pulp testing

31 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September :24 PM) © 2005 Elsevier

32 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September :24 PM) © 2005 Elsevier

33 Periodontal Examination n Probing n Mobility

34 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September :24 PM) © 2005 Elsevier

35 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

36 Special tests n Caries removal n Selective anesthesia n Transillumination n Sinus tract tracing

37 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September :24 PM) © 2005 Elsevier

38 Diagnosis and Tx Plans n Normal or reversible pulpitis –Remove cause n Irreversible pulpitis –RCT n Necrosis

39 Treatment choices n Routine cases n Difficult Procedures –Complications –Adjunctive procedures n Prognosis

40 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

41 Diagnosis n Pulpal: –Normal –Reversible –Irreversible –Necrotic –Extirpated n Periapical –Normal –Acute Apical Periodontitis –Chronic Apical Periodontitis –Acute Apical Abscess –Chronic Apical Abscess –Condensing Ostietis

42 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

43 Difficult diagnosis n Longitudinal fratures n Cracked tooth n Stressed tooth

44 Treatment Planning n To treat or not to treat n Treatment related to diagnosis n Number of appointments

45 Prognosis n Assess difficulty of case n Refer when needed

46 422 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

47 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:

48 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

49 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

50 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

51 n Diag: Irreversible pulpitis with chronic PA periodontitis n Tx plan: RCT, P+C, PFM Crown

52 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

53 n Dry canals n Cotton pellet n cavit

54 Reference n Principles & Practice of Endodontics 3 rd ed (2002) Walton & Torabinejad n Ch # 4

55 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)

56 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

57 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


Download ppt "Clinical Diagnostic Procedures Ch #4 Diagnosis & Tx Planning."

Similar presentations


Ads by Google