Presentation on theme: "Clinical Diagnostic Procedures"— Presentation transcript:
1 Clinical Diagnostic Procedures Ch #4 Diagnosis & Tx PlanningImportant topic= seperates the dentist from the auxillary.
2 Training in Basic Science enables: Perform diagnostic testsInterpret test results differentiallyPsychologically manage patient during testingFormulate 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 complaintTake relevant medical and dental historyConduct thorough Subjective- Objective- Radiographic examinationsAnalyze the data obtainedFormulate appropriate diagnosisDD is very demandingMay confuse both pt and dentist- most people equate pain w endoStructures Other that teeth may cause pain GIVE ME EXAMPLES?(periodontium- jawas-sinuses –ears- TMJ- masticatory muscles- nose- eyes- BV)Neuralogia- MS- MI- psychiatric disordersTherefore you need a step by step approach to diag + tx planning:
4 Scope of Endodontics Vital Pulp therapy Nonsurgical RCT Endo Surgery RetreatmentHemisection-Root AmputationBleachingIntentional replantationEndodontic Endosseous implantsApexificationApexogenesisTransplantationTreatment of traumaPerio-endo pathosisOrtho-endodonticsEndo 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 baseShould know when to consult and refer.
6 Systematic Approach to diagnosis Ascertain chief complaintDD is very demandingMay confuse both pt and dentist- most people equate pain w endoStructures Other that teeth may cause pain GIVE ME EXAMPLES?(periodontium- jawas-sinuses –ears- TMJ- masticatory muscles- nose- eyes- BV)Neuralogia- MS- MI- psychiatric disordersTherefore you need a step by step approach to diag + tx planning:
7 Diagnosis Chief Complaint First information obtained Problem expressed in patient’s own wordsRecorded in non-technical languageIf referred may be “No CC”
9 Diagnosis Ascertain chief complaint Take relevant medical and dental historyDD is very demandingMay confuse both pt and dentist- most people equate pain w endoStructures Other that teeth may cause pain GIVE ME EXAMPLES?(periodontium- jawas-sinuses –ears- TMJ- masticatory muscles- nose- eyes- BV)Neuralogia- MS- MI- psychiatric disordersTherefore you need a step by step approach to diag + tx planning:
10 Health History Comprehensive for new patients Update data of prior patientsDemographic dataMedical HistoryCurrent MedicationsDental HistoryChief complaintPresent illness
12 Medical History There are no absolute C/I to endodontics Endodontics is less traumatic than extractionOlder patients are in need of RCTCases that need precautionary measuresWhen consultations are neededIt 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
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 insiteMay explain subtle findings- short roots and resorption= hx of orhto
16 Diagnosis Ascertain chief complaint Take relevant medical and dental historyConduct thorough Subjective- Objective- Radiographic examinationsDD is very demandingMay confuse both pt and dentist- most people equate pain w endoStructures Other that teeth may cause pain GIVE ME EXAMPLES?(periodontium- jawas-sinuses –ears- TMJ- masticatory muscles- nose- eyes- BV)Neuralogia- MS- MI- psychiatric disordersTherefore you need a step by step approach to diag + tx planning:
17 1.Subjective Examination Present IllnessPainTentative diagnosisThese 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 testsPain may affect pt;s psychologyDr must be open, caring, and interested to elicit the most infoAsk further probing questionsReiterate to the patient what they said in a clear manner.
19 Pain Intensity Intense irreversible pathosis Recent, not long standing Unrelieved by analgesicIntermittentIrreversible pulpitisAcute apical periodontisits or abscessPain 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 coldUsually irreversible pulpitis
21 Continuous pain Lingering type of pain after removal of stimulus Continuous pain with thermal stimulus= irreversible pulpitisContinuous pain after application of pressure = periradicular pathosis
22 Tentative diagnosis Careful subjective questions Rule out non-odontogenic causesUrgency of treatment determinedConfirmed 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:
26 Dentition Discoloration Fractures Abrasions Erosions Caries Large restorations
27 Clinical tests Complex Process Tests of patients response! Presence of limitationsMay be inconclusiveSupplementary confirmatory tests neededFalse-neg + False-posControl teethFunc 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
30 Pulp vitality tests Cold tests Direct dentin stimulation Heat tests Electric pulp testingResponse 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 presenceDDS: 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-heatES 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 responseBlood flow determination: developing technology
33 Periodontal Examination ProbingMobilityPeriodontal 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
35 3.Radiographic examination Periapical lesions (of odontogenic origin):LD is lost apicallyAngulation does not change positionLucency resembles a hanging dropUsually cause of necrosis is evidentCondensing ostietis- enostosisPulpal lesionsThe great PretendersVery useful and necessary but do not overlook limitations. WHAT ARE THEYPathologic changes in pulp not visiblePAL in early stages do not show changesWill only show if the inflammation reaches cortical plates2D of 3d imageWHAT R THEY GOOD FOR:CariesDefective restoRCTAbnormal pulp and PAMalpositoned teethRelationship of nerves to apexGeneral bone patternPerio diseasepA lesions: important to DD from non-odontogenicPulp lesions: not visible- smaller pulp space- diffuse calcification- stones
36 Special tests Caries removal Selective anesthesia Transillumination Sinus tract tracingIf 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 directionFracture will not transmit light
40 Systematic Approach to diagnosis Ascertain chief complaintTake relevant medical and dental historyConduct thorough Subjective- Objective- Radiographic examinationsAnalyze the data obtainedWe reach analysis:
41 Diagnosis Periapical Pulpal: Normal Normal Acute Apical Periodontitis Chronic Apical PeriodontitisAcute Apical AbscessChronic Apical AbscessCondensing OstietisPulpal:NormalReversibleIrreversibleNecroticExtirpated
42 Acute Apical Periodontitis Pain on mastication or pressure Response Diagnosissymptomsradiographicpulp testsPA testsTreatmentPulpalNormalNoneRespondsNot sensitive None (unless intentional)Reversible Pulpitismay or may not have slight symptoms to theraml stimuliNo PA changesRemove causeIrreversible Pulpitismay or may not have slight symptoms to thermal stimulimay have spontaneous or severe pain to thermal stimulicondensing ostetismay have severe pain on stimulusmay or may not have pain on percussion and palpationRCTPulpotomy, pulpectomyExtractionNecrosisPANo responsePeriapicalAcute Apical PeriodontitisPain on mastication or pressureResponsePain on percussion or palpationChronic apical periodontitismildApical radiolucencyMild pain on percussion or palpationAcute Apical AbscessSwellingSignificant painUsually RL lesionPain on percussionDebridementDrainingChronic Apical abscessDraining sinusCondensing OsteitisvariableIncrease bone densityVariable
43 Difficult diagnosis Longitudinal fratures Cracked tooth Stressed tooth No need for rushLongitudinal crown: challenge for diag + txCracked tooth:Stressed tooth large resto
44 Treatment Planning To treat or not to treat Treatment related to diagnosisNumber of appointmentsExtract- emergency- retreatment ( surgically or retx and observe and then surgery)- pt explanantion- time bombNormal and Rev= solve problem, Irrever + necrosis= RCT, periapical swelling= ID, periapical RL= RCT + surgerySingle 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 PrognosisAssess difficulty of caseRefer when needed
47 GUIDELINES FOR EVALUATION Name:Number of canalsPoints per canalTotal Points for all canalsExtra Procedure pointsComputer No.: ________________________Total Points for caseGUIDELINES FOR EVALUATIONProceduresSessionSignature-No instructor's permission/sign0 + suspension123456No or improper Diagnosis-2.5History, Examination, DiagnosisNo or improper RD isolationFailure/ -2.5Patient management/LAImproper patient managementIsolationIneffective LAAccess cavityN/AACCESSWorking lengthUnder-extended-1.5InstumentationOver-extendedObturationImproper location/gouging-3Special ProceduresPerforationWLKnowledgeImproper sizeTime ManagementUnder/over ext. >2mmINSTRUM. MACTOTAL GRADE [Faculty]:Signature:Improper MAFCourse Director's Grade:Apical perforationStripping perforationFINAL GRADE [out of 10]:Broken instrumentFlushRoot CanalRef. PointInt WLMAFMCNot flaredSLOBTURATIONShortOver-extended GPSealer ext.-1Voids apicallyVoids middle/coronal-2Recall ExaminationPrognosisNo intermediate RGNo final RGDateFindingsGoodNo final resto-5ClinicalRadiographicPoorTreating wrong toothGuardedNo medical historySurgeryLikelyComments: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 URQMed 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: NADIOE: NAD tissues, large caries lesion in #16
50 Rad: small PA RL related to apex of #16 Tests: #16:Pain on perc + palpSevere lingering pain with Ice test (Endo frost)Early response with EPTNo pocketsNo mobiliyRad: 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 AccessFiling and irrigationMB19.5 mm30 kDBP21 mm40 k
54 ReferencePrinciples & Practice of Endodontics 3rd ed (2002) Walton & TorabinejadCh # 4
55 HomeworkWrite a table (or mind map) outlining medical conditions that may contraindicate or alter endodontic therapyOutline clinical endodontic tests in a thorough, logical manner (tables or mindmaps can be used)
57 Sign and dismiss patient @ 4:30 pm PROMPTLY ClinicAttendance sheet will be removed after 15 mnsYou 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 groupDon’t forget to sign evaluation formsSign and dismiss 4:30 pm PROMPTLY