Presentation is loading. Please wait.

Presentation is loading. Please wait.

Clinical Diagnostic Procedures

Similar presentations


Presentation on theme: "Clinical Diagnostic Procedures"— Presentation transcript:

1 Clinical Diagnostic Procedures
Ch #4 Diagnosis & Tx Planning Important topic= seperates the dentist from the auxillary.

2 Training in Basic Science enables:
Perform diagnostic tests Interpret test results differentially Psychologically manage patient during testing Formulate diagnosis and treatment plan. Only the dentist has training in basic sciences that enable and entitles him to :

3 Systematic Approach to diagnosis
Ascertain chief complaint Take relevant medical and dental history Conduct thorough Subjective- Objective- Radiographic examinations Analyze the data obtained Formulate appropriate diagnosis DD is very demanding May confuse both pt and dentist- most people equate pain w endo Structures Other that teeth may cause pain GIVE ME EXAMPLES? (periodontium- jawas-sinuses –ears- TMJ- masticatory muscles- nose- eyes- BV) Neuralogia- MS- MI- psychiatric disorders Therefore you need a step by step approach to diag + tx planning:

4 Scope of Endodontics Vital Pulp therapy Nonsurgical RCT Endo Surgery
Retreatment Hemisection-Root Amputation Bleaching Intentional replantation Endodontic Endosseous implants Apexification Apexogenesis Transplantation Treatment of trauma Perio-endo pathosis Ortho-endodontics Endo has a wide scope not limited to RCT it includes: A GP should obviously deal w RCT but also some aspects of endo modalities, others that are too complex should be refered

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
Ascertain chief complaint DD is very demanding May confuse both pt and dentist- most people equate pain w endo Structures Other that teeth may cause pain GIVE ME EXAMPLES? (periodontium- jawas-sinuses –ears- TMJ- masticatory muscles- nose- eyes- BV) Neuralogia- MS- MI- psychiatric disorders Therefore you need a step by step approach to diag + tx planning:

7 Diagnosis 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 2006 07:24 PM)
© 2005 Elsevier

9 Diagnosis Ascertain chief complaint
Take relevant medical and dental history DD is very demanding May confuse both pt and dentist- most people equate pain w endo Structures Other that teeth may cause pain GIVE ME EXAMPLES? (periodontium- jawas-sinuses –ears- TMJ- masticatory muscles- nose- eyes- BV) Neuralogia- MS- MI- psychiatric disorders Therefore you need a step by step approach to diag + tx planning:

10 Health History Comprehensive for new patients
Update data of prior patients Demographic data Medical History Current Medications Dental History Chief complaint Present illness

11 Demographic data Identify Pt characteristics

12 Medical History There are no absolute C/I to endodontics
Endodontics is less traumatic than extraction Older patients are in need of RCT Cases that need precautionary measures When consultations are needed It aids diag as well as show pt’s susceptibility tp infections-bleeding, shows medications, and emotional status.

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

14 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM)
© 2005 Elsevier

15 Dental History Pay attention to state of patient Ask probing questions
Establish good rapport and caring attitude. Shows attitude of patient regarding dental care. Diagnositic value and tx plan insite May explain subtle findings- short roots and resorption= hx of orhto

16 Diagnosis Ascertain chief complaint
Take relevant medical and dental history Conduct thorough Subjective- Objective- Radiographic examinations DD is very demanding May confuse both pt and dentist- most people equate pain w endo Structures Other that teeth may cause pain GIVE ME EXAMPLES? (periodontium- jawas-sinuses –ears- TMJ- masticatory muscles- nose- eyes- BV) Neuralogia- MS- MI- psychiatric disorders Therefore you need a step by step approach to diag + tx planning:

17 1.Subjective Examination
Present Illness Pain Tentative diagnosis These are exams to evaluate S & S in a way that is expressed by patient , they are not measurable, and differ from one person to the next

18 Present Illness Only if a patient has a sign problem
If no sign symptoms go on to objective tests Pain may affect pt;s psychology Dr must be open, caring, and interested to elicit the most info Ask further probing questions Reiterate to the patient what they said in a clear manner.

19 Pain Intensity Intense irreversible pathosis Recent, not long standing
Unrelieved by analgesic Intermittent Irreversible pulpitis Acute apical periodontisits or abscess Pain may be intermittent, w feeling of jabs, or it may be continous, steady and dull. Severe pain may be assoc w cardiac systole. Other nondental pain may be bright and paroxysmal (neuralgia), or dull (myofascial pain) The aspects of pain that are strongly indicative of pulpal and periradicular pathosis are: Intensity- spontaneaty, and continuety or persistance.

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

21 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 Careful subjective questions
Rule out non-odontogenic causes Urgency of treatment determined Confirmed or denied by hands-on oral examination and clinical tests. After taking med and dx hx, and identify major aspects of subj S + S of present illness dr reaches:

23 2.Objective Examination
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 2006 07:24 PM)
© 2005 Elsevier

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

26 Dentition Discoloration Fractures Abrasions Erosions Caries
Large restorations

27 Clinical tests Complex Process Tests of patients response!
Presence of limitations May be inconclusive Supplementary confirmatory tests needed False-neg + False-pos Control teeth Func of control teeth: 1. the pt learns what to expect, 2. the dentist can observe pt response to a certain level of stimulus, 3. dentist can learn which stimulus will provoke a rsponse.

28 Periapical tests Percussion Palpation
Indicative of periradicular inflamation

29 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM)
© 2005 Elsevier

30 Pulp vitality tests Cold tests Direct dentin stimulation Heat tests
Electric pulp testing Response does not guarantee a pulp’s viability of health, but at least presence of some nerve fibers carrying sensory impulses. Which test to use: something that provokes a response similar to pt reports. Cold test: Ice, CO2, refrigerant, techniques, false neg(calcified canals) and positive(contact gingiva)-laack of response not as indicative as presence DDS: scratch expose dentin- absence is not as indicative as presence o response, test cavity ex crowned tooth. Heat: isolate tooth to prevent false postive, GP, dry prophy cup-frictional heat, some devices, such as touch-n-heat ES similar to cold.applied after cold test, clean, dry and isolate tooth, conducting medium, complete circuit, false +, and false – (calcific metamorphosis), only yes or no response Blood flow determination: developing technology

31 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM)
© 2005 Elsevier

32 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM)
© 2005 Elsevier

33 Periodontal Examination
Probing Mobility Periodontal lesions may mimic endo and important to differentiate. Probing: may be induced by perio or Pa, size and depth are important to distinguish. Affect prognosis as well. Mobility: status of PDL and prognosis (more than 2-3 mm or depression-poor candidate). Extensive PA lesion may > mobility and Decreases after endo

34 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM)
© 2005 Elsevier

35 3.Radiographic examination
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 Pulpal lesions The great Pretenders Very useful and necessary but do not overlook limitations. WHAT ARE THEY Pathologic changes in pulp not visible PAL in early stages do not show changes Will only show if the inflammation reaches cortical plates 2D of 3d image WHAT R THEY GOOD FOR: Caries Defective resto RCT Abnormal pulp and PA Malpositoned teeth Relationship of nerves to apex General bone pattern Perio disease pA lesions: important to DD from non-odontogenic Pulp lesions: not visible- smaller pulp space- diffuse calcification- stones

36 Special tests Caries removal Selective anesthesia Transillumination
Sinus tract tracing If still haven’t made a Dx = tx plan: Deep caries-no ss-responds? When pain-cannot isolate offending tooth-most effective in max- ant to post direction Fracture will not transmit light

37 Downloaded from: Pathways of the Pulp, 9th edition (on 15 September 2006 07:24 PM)
© 2005 Elsevier

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

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

40 Systematic Approach to diagnosis
Ascertain chief complaint Take relevant medical and dental history Conduct thorough Subjective- Objective- Radiographic examinations Analyze the data obtained We reach analysis:

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

42 Acute Apical Periodontitis Pain on mastication or pressure Response
Diagnosis symptoms radiographic pulp tests PA tests Treatment Pulpal Normal None Responds Not sensitive None (unless intentional) Reversible Pulpitis may or may not have slight symptoms to theraml stimuli No PA changes Remove cause Irreversible Pulpitis may or may not have slight symptoms to thermal stimuli may have spontaneous or severe pain to thermal stimuli condensing ostetis may have severe pain on stimulus may or may not have pain on percussion and palpation RCT Pulpotomy, pulpectomy Extraction Necrosis PA No response Periapical Acute Apical Periodontitis Pain on mastication or pressure Response Pain on percussion or palpation Chronic apical periodontitis mild Apical radiolucency Mild pain on percussion or palpation Acute Apical Abscess Swelling Significant pain Usually RL lesion Pain on percussion Debridement Draining Chronic Apical abscess Draining sinus Condensing Osteitis variable Increase bone density Variable

43 Difficult diagnosis Longitudinal fratures Cracked tooth Stressed tooth
No need for rush Longitudinal crown: challenge for diag + tx Cracked tooth: Stressed tooth large resto

44 Treatment Planning To treat or not to treat
Treatment related to diagnosis Number of appointments Extract- emergency- retreatment ( surgically or retx and observe and then surgery)- pt explanantion- time bomb Normal and Rev= solve problem, Irrever + necrosis= RCT, periapical swelling= ID, periapical RL= RCT + surgery Single visit acceptable- multiple depends on: tolerance and experience of operator, fatigue of pt-pain- retx- necessity of placement of CaOH, effect of prog none, pain; no difference, finish appoint when you completely debride

45 Prognosis Assess difficulty of case Refer when needed

46 Clinical Endodontic Form
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: DIAGNOSTIC TESTS: THERAPY: None Swelling (intra/extraoral) Test Result Caries 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 Response Faculty 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 Internal/external resorption 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 Perio Broken instrument Acute apical periodontitis Cracked tooth Perforation Chronic apical periodontitis Endo previously initiated Acute apical abscess Overdenture Chronic apical abscess Condensing osteitis

47 GUIDELINES FOR EVALUATION
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 1 2 3 4 5 6 No or improper Diagnosis -2.5 History, Examination, Diagnosis No or improper RD isolation Failure/ -2.5 Patient management/LA Improper patient management Isolation Ineffective LA Access cavity N/A ACCESS Working length Under-extended -1.5 Instumentation Over-extended Obturation Improper location/gouging -3 Special Procedures Perforation WL Knowledge Improper size Time Management Under/over ext. >2mm INSTRUM. MAC TOTAL GRADE [Faculty]: Signature: Improper MAF Course Director's Grade: Apical perforation Stripping perforation FINAL GRADE [out of 10]: Broken instrument Flush Root Canal Ref. Point Int WL MAF MC Not flared S L OBTURATION Short Over-extended GP Sealer ext. -1 Voids apically Voids middle/coronal -2 Recall Examination Prognosis No intermediate RG No final RG Date Findings Good No final resto -5 Clinical Radiographic Poor Treating wrong tooth Guarded No medical history Surgery Likely Comments: Faculty's Grade:

48 Sample Clinical Notes 20 year old female patient
CC: “ I have a swelling and broken down tooth in my mouth” points to URQ Med Hx: Juvenile Diabetes – controlled with medication (Insulin Injections 2X/day) Dent Hx: Several extractions, fillings, and RCT

49 Pain: in URQ started 2 weeks ago, wakes her up at night
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. EOE: NAD IOE: NAD tissues, large caries lesion in #16

50 Rad: small PA RL related to apex of #16
Tests: #16: Pain on perc + palp Severe lingering pain with Ice test (Endo frost) Early response with EPT No pockets No mobiliy Rad: small PA RL related to apex of #16

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

52 Tx today: IDNB 2% lidocaine – 2 carpules Isolation Caries excavation
Access Filing and irrigation MB 19.5 mm 30 k DB P 21 mm 40 k

53 Dry canals Cotton pellet cavit

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

55 Homework Write a table (or mind map) outlining medical conditions that may contraindicate or alter endodontic therapy Outline clinical endodontic tests in a thorough, logical manner (tables or mindmaps can be used)

56 Next week’s lecture Isolation Radiography
Access Preparation & Length determination Cleaning & Shaping Obturation Ch.8 Ch. 9 Ch. 12 Ch. 13 Ch. 14

57 Sign and dismiss patient @ 4:30 pm PROMPTLY
Clinic Attendance sheet will be removed after 15 mns You will have 2 patients each to examine and fill out endo forms. Your instructor will show you how to perform clinic tests for the whole group Don’t forget to sign evaluation forms Sign and dismiss 4:30 pm PROMPTLY


Download ppt "Clinical Diagnostic Procedures"

Similar presentations


Ads by Google