CLINICAL DIAGNOSIS OF ENDODONTIC PATHOSIS
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A brief overview of the basic concepts for endodontic diagnosis
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CLINICAL DIAGNOSIS OF ENDODONTIC PATHOSIS
- 2. • Introduction • Significance of Diagnosis • Brief Overview Of History Taking • Clinical Examination: Objective Findings • Sensibility Testing • Radiographic Interpretation • Diagnostic Scheme Pulpal Diagnosis Normal Reversible Pulpitis Irreversible Pulpitis Necrosis Periapical Diagnosis Normal Acute Apical Periodontitis Chronic Apical Periodontitis Acute Apical Abscess Chronic Apical Abscess Condensing Osteitis • Other Diagnostic Possibilities • Case Reports • CONCLUSION • REFERENCES
- 3. INTRODUCTION • “Diagnosis is the process of identifying a disease by careful investigation of its symptoms and history” MEDICAL /DENTAL HISTORY CLINICAL EXAMINATION SPECIAL TESTS RADIOLOGICAL EXAMINATION DIAGNOSIS
- 4. ENDODONTIC TRIAD CONTEMPORARYTRADITIONAL DEBRIDEMENT STERILIZATION APICAL SEAL DIAGNOSIS ANATOMY, DEBRIDEMENT OBTURATION SUCCESS SUCCESS
- 5. CASE HISTORY TAKING • Statistics • Chief complaint • History of present illness • Medical history • Past dental history • Personal history • General examination • Extraoral examination • Intraoral examination • Provisional diagnosis • Investigations • Final diagnosis • Treatment plan
- 6. s . (Adapted from Krell K, Walton R: Odontalgia: diagnosing pulpal, periapical, and periodontal pain. In Clark J, editor: Clinical dentistry, Philadelphia, 1987, Harper & Row.)
- 7. OVERVIEW 1. Assemble all available facts Chief complaint History of present condition Medical & Dental History 2. Screen & interpret the assembled clues and discover which are genuine to the case 3. Differential Diagnosis 4. Operational/ working diagnosis/ final diagnosis Subjective symptoms Four components of diagnostic procedure
- 8. HISTORY OF PRESENT ILLNESS 1. How long have you had the pain? 2. Do you know which tooth it is? 3. What initiates the pain? 4. How would you describe the pain? Sharp or dull Throbbing Mild or severe Localised or radiating 5. How long does the pain last? 6. Does it hurt most during the day or night? 7. Does anything relieve the pain?
- 10. PAIN Type of pain Sharp, piercing and lancinating Dull, borinq, gnawing, excruciating A-DELTA nerve fibers REVERSIBLE state. C-nerve fibers IRREVERSIBLE state Carrotte, P.Endodontics: Part 2 Diagnosis and treatment planning British Dental Journal 2004;9(1)
- 11. Duration of pain Shorter duration (1 minute)- longer duration REVERSIBLE PULPITIS IRREVERSIBLE PULPITIS Carrotte, P.Endodontics: Part 2 Diagnosis and treatment planning British Dental Journal 2004;9(1)
- 12. Localisation of pain Sharp piercing pain Dull pain Responds to cold Responds more abnormally to heat Carrotte, P.Endodontics: Part 2 Diagnosis and treatment planning British Dental Journal 2004;9(1)
- 13. Factors which provoke/ relieve pain MASTICATION STIMULATION PULP VITALITY PAIN IRREVERSIBLE PULPITIS Carrotte, P.Endodontics: Part 2 Diagnosis and treatment planning British Dental Journal 2004;9(1)
- 15. CLINICAL EXAMINATION Extraoral swelling Lymph node involvement Intraoral involvement Fistula Tooth discoloration Traumatic injuries: fractures Deep carious lesion Recurrent caries beneath a restoration Extensive restoration Developmental defects of teeth Gingival recession
- 17. VISUAL AND TACTILE INSPECTION Color Contour Consistency Normal crown- life like translucency Discolored opaque – inflamed, degenerated or necrotic pulp. Calcified Canal – Light Yellow Hue of the Crown Pink Tooth – Indicates Internal Resorption CROWN CONTOUR Wear Facets, Fractures and Restorations Caries Examination: Diagnodent- early caries diagnosis. Carrotte, P.Endodontics: Part 2 Diagnosis and treatment planning British Dental Journal 2004;9(1)
- 18. • Digital pressure is used to check for tenderness in the oral tissues overlying the suspected teeth. • Bimanual palpation is most efficient to detect incipient swellings before it is clinically evident PALPATION Carrotte, P.Endodontics: Part 2 Diagnosis and treatment planning British Dental Journal 2004;9(1)
- 19. Positive response :periodontitis (pericementitis) Teeth undergoing rapid orthodontic movement. High points in recent restorations Lateral periodontal abscess. Partial/total Pulpal necrosis. PERCUSSION Dull note- Signifies abscess formation. Sharp note- denotes Inflammation. Metallic note- Ankylosis Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
- 20. • Periodontal probing :sounding or walking the probe around the tooth, while pressing gently on the floor of the sulcus. • Isolated vertical bone loss -indicates vertical root fracture. • Furcation involvement. • Lateral canal - portal of entry for toxins- Pulpal Degeneration. Thermal and electric pulp tests must be performed along with periodontal examination to distinguish between disease of Pulpal and Periodontal origin. PERIODONTAL EXAMINATION Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
- 21. Assessment Tests for pulp vitality Radiographs Investigations
- 22. Assessment Tests for pulp vitality
- 23. THERMAL TESTS 1. No response - non vital or vital; but false-negative response due to excessive calcifications, immature apex, recent trauma, patient medication etc. 2. Painful response-subsides when stimulus is removed from the tooth- Reversible- pulpitis. 3. Moderate, transient response- Normal. 4. Painful response- lingers after removal of stimulus- Irreversible Pulpitis. Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
- 24. Caries Sharp outline of the root Tooth length Number of roots and canals Calcification Hard tissue deposits Internal/External resorption Periapical lesions Perforations Fractures RADIOGRAPHS Caries progression - radiographic grades Grade 1 – Caries in enamel Grade 2 – Reaches the DE junction Grade 3 – Radiolucency extends halfway into dentin thickness Grade 4 – Deeper dentin Grade 5 – involving the pulp Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
- 25. Caries Examination Receding pulp horn – age changes, chronic carious lesion In Posterior teeth Mesial Carious Lesion – more commonly involves pulp Distal Carious Lesion – takes a longer time Morphological features of root canal: Length – longer or shorter Shape : Blunder buss Taurodontism Dens in Dente Root with bulbous ends Curved canals – Degree of curvature X- ray exposed at 15º horizontal angle can help visualize curvature in bucco-lingual plane Deep caries involvement of mesial pulp horn causes minimal periapical changes either in mesial/distal root Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
- 26. Number of canals : Extra canals (Mandibular Incisor & Premolar, Maxillary First Molar) When large canals stop abruptly, look for branching Resorption : Internal resorption – Continuous with canal External resorption – Super imposed. Calcification Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
- 27. DIAGNOSTIC TESTS PULP TISSUES PERIAPICAL TISSUES Thermal (cold, hot) Electric pulp test Direct dentinal stimulation (cavity test) •Percussion •Palpation •Periodontal ligament •Selective anesthesia test
- 28. Normal pulp: Reversible pulpitis: Symptomatic irreversible pulpitis : Asymptomatic irreversible pulpitis Pulp necrosis Previously treated Previously initiated therapy PULPAL DIAGNOSIS Diagnostic terminology approved by the American Association of Endodontists and the American Board of Endodontics Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
- 29. CLI NICAL CHARACTERISTICS OF REVERSIBLE PULPITIS • Sensitivity to mild discomfort • Short duration or shooting sensation • Not severe• • Infrequent episodes of discomfort • Common causes: – exposed dentin, – cracked restorations, – recently placed restorations, – initial carious attack or rapidly advancing caries – altered occlusion • Symptoms usually subside immediately or shortly after removal of the cause Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
- 30. CLINICAL CHARACTERISTICS OF IRREVERSIBLE PULPITIS • Pain may be absent or present • If present- moderate to severe • Spontaneous, increasing in frequency, often to a point of being continuous • Pain usually lingers, especially with increasing episodes • Thermal stimulation often elicits severe lingering pain • Pain radiates /diffuse / localized – History of trauma, – extensive restorations – periodontal disease or – extensive recurrent caries. Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
- 31. Normal pulp: Symptomatic apical periodontitis Asymptomatic apical periodontitis Chronic apical abscess Acute apical abscess Condensing osteitis APICAL DIAGNOSIS Diagnostic terminology approved by the American Association of Endodontists and the American Board of Endodontics Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
- 33. SUB - ACUTE PERIRADICULAR PERIODONTITIS • Slight tenderness to biting or percussion • No lesion present on radiographs ACUTE PERIRADICULAR PERIODONTITIS • Pain to biting or percussion • No thickened ligament space or lesion present • Tooth may be mobile • Often tender to palpation CLI NICAL CHARACTERI STICS Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
- 34. CHRONIC PERIRADICULAR PERIODONTITIS • Patient asymptomatic • If sinus tract present, referred to as suppurative • Percussion produces little or no discomfort ACUTE ALVEOLAR ABSCESS • Severe pain with biting, percussion and palpation • Tooth elevated in the socket • Tooth mobile • Swelling may be present • Often systemic symptoms present CLI NICAL CHARACTERI STICS Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619.
- 36. CARIES: • Demineralization of dentin :progressive; lacks a clear clinical or radiographic border. • Most carious lesions extend deeper into the dentin than what can be ascertained radiographically. • Carious lesions that appear near pulp horns also are likely to be carious exposures upon excavation Gutmann, James L. Problem solving in endodontics : prevention, identification, and management—5th ed, 2011
- 37. • Radiographic appearance of recurrent decay -margins of existing restorations. • Caries beginning at the depth of a previous caries excavation – usually involves the pulp • Caries under existing crowns appears along the margin but may extend extensively under the clinical crown If the RDT is <0.5 mm, close proximity of the pulp-dentinal wall appears pink. Studies show that with an RDT of less than 0.5 mm, the prognosis for pulp survival is doubtful. Gutmann, James L. Problem solving in endodontics : prevention, identification, and management—5th ed, 2011
- 38. Internal Resorption • Relatively symmetric radiolucency located in the mesial-distal center of the root. • Radiographs taken at any angle other than perpendicular to the tooth - confirm the central location of the defect in the root. • Key distinguishing radiographic finding : loss of the canal outline in the resorptive defect : Gutmann, James L. Problem solving in endodontics : prevention, identification, and management—5th ed, 2011
- 39. External Resorption • Originates from the periodontium and invades the tooth on the external surface of the root. • Defects :irregular shape and are not centrally located in the root. • Many seem to originate at the level of crestal bone in the marginal periodontium and are discovered clinically as a defect in the root surface below the free gingival margin • A key distinguishing factor in most cases is the continued presence of the canal through the resorptive defect • This problem is not of pulpal origin, so the shape of the root canal space is unaltered. Gutmann, James L. Problem solving in endodontics : prevention, identification, and management—5th ed, 2011
- 40. Vertical Root Fractures • Frequent cause of tooth loss almost unique to root-treated teeth. • Consistent location of the crack lines :midfacial/buccal or 180 degrees on the midlingual/palatal regions of most roots. • Lack of separation of fractured segments of the root: seldom visible radiographically. • Etiology: anatomic, restorative, periodontal, or endodontic • Characteristic radiographic change: adjacent bone; result of bone resorption along the fracture line. • Early changes :lateral widening of the periodontal ligament space. with no apical involvement. • As bone resorption continues: a distinct lateral radiolucency parallel to root surface • When a fracture is visible and significant separation of the fractured segments of the root has occurred, the fracture has probably been present for a long time Gutmann, James L. Problem solving in endodontics : prevention, identification, and management—5th ed, 2011
- 41. Endodontic Failure • Root-treated teeth that fail: develop lesions radiographically identical to lesions -extension of pulpal infection to periapical bone • Lesions may occur at the apex/ site of a lateral canal • Most respond to nonsurgical revision, after which periodontal ligament and lamina dura will reappear • If an asymptomatic periapical lesion discovered on routine examination- ask the patient when treatment was performed. • Lesions - 3 to 12 months to resolve following retreatment. • If the treatment in question was completed <12 months prior to examination, -radiographic reevaluation of the lesion in 6 months. • If the treatment had been completed > 2 years previously, tooth may be presumed to have recurrent pathosis -indicated for treatment revision in most cases. Gutmann, James L. Problem solving in endodontics : prevention, identification, and management—5th ed, 2011
- 43. Pulp Stones • Discrete calcifications -within the pulp chamber. • May lie free within the pulp, adhere to the chamber wall, or become embedded in dentin. • Pulp stones that become sufficiently large (i.e. >200 μm in maximum diameter) may be detected incidentally on bitewing or periapical radiographs. Gutmann, James L. Problem solving in endodontics : prevention, identification, and management—5th ed, 2011
- 44. Hyperplastic Pulpitis • Represents an inflammatory enlargement of the pulp • Typically develops in the teeth of young patients with large pulpal exposures. • The absence of a pulp chamber roof and the presence of open root apices may reduce intrapulpal pressure, maintain the microcirculation, and decrease the likelihood of pulpal necrosis. Gutmann, James L. Problem solving in endodontics : prevention, identification, and management—5th ed, 2011
- 45. CASE REPORTS
- 46. A mandibular right first molar had been hypersensitive to cold and sweets over the past few months but the symptoms have subsided Now there is no response to thermal testing and there is tenderness to biting and pain to percussion. Radiographically, there are diffuse radiopacities around the root
- 47. Following the placement of a full gold crown on the maxillary right second molar, a patient complained of sensitivity to both hot and cold liquids; now the discomfort is spontaneous Upon application of Endo-Ice® on this tooth, the patient experienced pain and upon removal of the stimulus, the discomfort lingered for 12 seconds. Responses to both percussion and palpation were normal; radiographically, there was no evidence of osseous changes.
- 48. • A maxillary left first molar has occlusal-mesial caries and the patient has been complaining of sensitivity to sweets and to cold liquids. There is no discomfort to biting or percussion. The tooth is hyper-responsive to Endo-Ice® with no lingering pain.
- 49. A mandibular right lateral incisor has an apical radiolucency that was discovered during a routine examination.There was a history of trauma more than 10 years ago and the tooth was slightly discolored. The tooth did not respond to Endo-Ice® or to the EPT; the adjacent teeth responded normally to pulp testing. There was no tenderness to percussion or palpation in the region.
- 50. • A mandibular left first molar demonstrates a relatively large apical radiolucency encompassing both the mesial and distal roots along with furcation involvement.Periodontal probing depths were all within normal limits. The tooth did not respond to thermal (cold) testing and both percussion and palpation elicited normal responses. There was a draining sinus tract on the mid-facial of the attached gingiva which was traced with a gutta-percha cone. There was recurrent caries around the distal margin of the crown.
- 51. • A maxillary left first molar was endodontically treated more than 10 years ago. The patient is complaining of pain to biting over the past three months. There appear to be apical radiolucencies around all three roots. The tooth was tender to both percussion and to the Tooth Slooth
- 52. • A maxillary left lateral incisor exhibits an apical radiolucency. There is no history of pain and the tooth is asymptomatic. There is no response to Endo-Ice® or to the EPT, whereas the adjacent teeth respond normally to both tests. There is no tenderness to percussion or palpation
- 53. CONCLUSION A careful evaluation of the patient’s clinical presentation and pathosis is key to establishing a sound endodontic diagnosis MYSTERY OR MASTERY??
- 54. References [1]Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod 2009;35:1619. [2] Seltzer S, Bender IB, Ziontz M. The dynamics of pulp inflammation: correlations between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol 1963;16:846-71;969–977. [3] Berman LH, Hartwell GR. Diagnosis. In: Cohen S, Hargreaves KM, eds. Pathways of the Pulp, 11th ed. St. Louis, MO: Mosby/ Elsevier; 2011:2–39. [4] Schweitzer JL. The endodontic diagnostic puzzle. Gen Dent 2009; Nov/Dec. 560–567. [5] AAE Consensus Conference Recommended Diagnostic Terminology. J Endod 2009;35:1634. [6] American Association of Endodontists. Glossary of Endodontic Terms. 8th ed. 2012. [7] Glickman GN, Bakland LK, Fouad AF, Hargreaves KM, Schwartz SA. Diagnostic terminology: report of an online survey. J Endod 2009;35:1625. [8] Abbott PV, Yu C. A clinical classification of the status of the pulp and the root canal system. Aust Dent J 2007;52 (Endod Suppl):17–31.
Hinweis der Redaktion
- Explain chief complaint, hopi A sample form used in diagnosis and treatment planning
- Examples of the type of questions which may be asked are given below: EXPLAIN In cases of pulpitis, the decision the operator must make is whether the pulpal inflammation is reversible, in which case it may be treated conservatively, or irreversible, in which case either the pulp or the tooth must be removed, depending upon the patient’s wishes. If symptoms arise spontaneously, without stimulus, or continue for more than a few seconds after a stimulus is withdrawn, the pulp may be deemed to be irreversibly damaged. Applications of sedative dressings may relieve the pain, but the pulp will continue to die until root canal treatment becomes necessary. This may then prove more difficult if either the root canals have become infected or if sclerosis of the root canal system has occurred. The correct diagnosis, once made, must be adhered to with the appropriate treatment. In early pulpitis the patient often cannot localise the pain to a particular tooth or jaw because the pulp does not contain any proprioceptive nerve endings. As the disease advances and the periapical region becomes involved, the tooth will become tender and the proprioceptive nerve endings in the periodontal ligament are stimulated
- History of present illness+ Intra oral examination-cisual and tactile + Radiographic + Other Tests: Subjective Symptoms are those which are experienced and reported to the clinician by the patient. 2. Objective Symptoms are those, which are obtained by the clinician through various tests
- Grossman has stated Pulpal pain to be of the following two varieties : Accordong to Grossman: Ø Sharp, piercing and lancinating -- a painful response usually associated with the excitation of the A-DELTA nerve fibers. This pain usually reflects REVERSIBLE state. Ø Dull, borinq, gnawing and excruciating-- a painful response usually associated with the excitation of C-nerve fibers.- Ø Usually reflects an irreversible state of pulpitis.
- Grossman has stated Pulpal pain to be of the following two varieties : - Excellent chance of recovery without the need for endodontic treatment-rev case
- Patients may report that their dental pain is exacerbated while lying down or bending over This occurs because of the increase in blood pressure to the head, which therefore increases the pressure on the confined pulp
- Thus pain, which is recorded as the complaint is considered to conclude an acute or chronic, reversible or irreversible condition of the pulp.
- Rev pulpitis: Characterized by pain which is of a :- Shorter duration Localized May be piercing/ lancinating in nature More responsive to cold than heat Caused by a specific irritant & disappears as soon as it is removed 19. Irrev: Abnormal dental pain, which responds to heat Which occurs on changing the position of the head, awakening the patient from sleep Dull pain of Longer duration, which occurs during mastication in a Cariously exposed tooth
- The clinician should look for: Facial asymmetry Localized swellings Lymphadenopathy Changes in color, bruises/ scars, similar signs of disease, trauma or of any various treatment. Begins with a general evaluation of the oral structures. The occlusion is checked (for any derangements if any) The lips, cheeks, vestibules and mucosa are examined for any evident abnormalities.
- Simplest and the easiest of the diagnostic tests Acc. To Grossman the prime objective of visual & tactile inspector is evaluation of the “3 C’s” viz: of hard and soft tissues Soft tissue: Color- the normal color of gingiva is coral pink. Change from this is easily visualized in inflammatory conditions. Contour- change in normal contour (eg, of scalloped gingiva) occurs with a swelling. Consistency- On inspection (most commonly gingiva) appears healthy, firm, resilient, while a soft, fluctuant or spongy tissue is more indicative of a pathological state. Color- Normal teeth show life like translucency & sparkle that is missing in pulpless teeth which appear more or less opaque. Note: This discoloration however could be due to a variety of other reasons like old amalgam restorations, tetracycline stains etc. Contour- This examination should also include the visualization of contours of affected teeth, such as fractured teeth, wear facets, improperly contoured restorations, or altered crown contours as these factors can have a marked effect on the respective pulps. Consistency- Change in the consistency of hard dental tissues is related to the presence of caries, external and internal resorption
- Employs the usage of the (index finger) fingertip, supplemented with a light digital pressure to examine tissue consistency and pain response. The importance of this test other than as an aid in locating the swelling over an involved tooth, is in determining the following: Whether the tissue is fluctuant and enlarged sufficiently for incision and drainage. The presence, intensity and location of pain. The presence and location of Adenopathy The presence of bony Crepitus. Digital pressure is used to check for tenderness in the oral tissues overlying the suspected teeth.Bimanual palpation is most efficient to detect incipient swellings before it is clinically evident
- Before percussing the involved tooth, instructions are to be given to the patient to raise his/ her hand or make an audible sound in order to let the clinician know when and whether the tooth feels “TENDER”, “DIFFERENT” or painful on percussion. Before percussing the teeth with the handle of the instrument (a mouth mirror etc), the quadrant of the involved tooth is percussed using the index finger with quick blows of low intensity. The teeth should be tapped (with the index finger) in a random fashion so that the patient cannot “anticipate” when the tooth will be percussed When no response is elicited on digital percussion, then the handle of an instrument is to be used/employed. 27. Percussion is done in both vertical and horizontal directions. Change the sequence of percussion in successive tests to eliminate bias. The force of percussion should only be strong enough for the patient to differentiate between a sound tooth and a tooth with inflamed periodontal ligament. The proprioceptive fibers in an inflamed periodontal ligament will, when percussed, help the patient and the clinician locate the source of pain. 28. ormal resonant sound on percussion indicates good periodontal ligamentDull sound on percussion indicates ankylosis.Response to percussion not only indicates the involvement of the PDL but also the extent of the inflammation.(degree of response directly proportional to degree of inflammation). Chronic periapical inflammation is often negative to Percussion.
- Horizontal bone loss with generalized pocket is not as worrisome as
- Assessment of vitality using routine methods rely on the stimulation of Aδ nerve fibers and there is no direct indication of the blood flow. Three methods are used to stimulate the Aδ nerve fibers1. Thermal stimulation2. Electrical stimulation3. Direct dentin stimulation.
- 3 METHODS OF STIMULATION: READ FROM SLIDESHARE DIAGNOSSI CONCEPT Heat causes vasodilatation and increase in intrapulpal pressure (releases gaseous product ofproteolysis) (VAN HASSEL).In an intact pulp specific pulpal temperaturemust be reached before there is pain from heat. Therefore, application of heat to normal teethgives delayed response.In a tooth with inflamed pulp, increased intrapulpal pressure already exists. Thereforeimmediate painful response to gradual/suddenincrease in heat. 51. COLDCold decreases intrapulpal pressure in normal intact pulp and there is no pain.The pain from cold is due to hydrodynamic mechanism.Contraction of fluid causes outward flow of fluid in dentinal tubules, deforms Aδ nerve and an action potential is generated.In advanced acute pulpitis, no Aδ receptors are present. Cold produces contraction and lowers the intrapulpal pressure to a sub threshold level and relieves pain due to still viable C fibers.Pain returns within 30 – 60 seconds as intra pulpal pressure returns to its former suprathreshold level. 52. ELECTRIC PULP TEST Electrolyte applied on the teeth to transmit current Jelly used for ECG is ideal When electrolyte contacts the tooth an electric charge is applied by pressing rheostat button. A small charge is released initially and increased until response is felt. Select control teeth – contra lateral teeth and adjacent teeth. www.indiandentalacademy.com 53. INTERPRETATION If the current required to gain a response from a test tooth is same as that needed to excite the control – the pulp of the test tooth is considered normal. If less current is required for a response – Hyperactive If more current is required– delayed response/ high pain threshold Lack of response – Pulpal necrosis www.indiandentalacademy.com 54. Two readings are recorded and the average value is taken. “Using EPT on any tooth more than 4 times can give wrong reading due to additive action.” www.indiandentalacademy.com 55. Only Aδ fibers are activated by electric tests Aδ fibers produce initial momentary sharp response to electric stimuli because of its peripheral location, low threshold & greater conduction velocity. Continuous constant pain is produced by the smaller C fiber stimulation as it is associated with tissue damage and inflammatory process
- Calcificatin isolated or continuous
- The pulpal nerve fibers, A-delta (which respond to cold and the EPT) and C-fibers (which respond to heat and elicit the nerve response when a patient reports spontaneous tooth pain), are nociceptors. Nociceptors are sensory receptors that respond to stimuli by sending nerve signals to the brain. This stimulus can cause the perception of pain in an individual.9 By objectively testing the pulpal nerve fibers, a dentist can best determine pulpal status. Diagnostic terminology approved by the American Association of Endodontists and the American Board of Endodontics5-7 Pulpal diagnoses9-\ One cannot arrive at a probable diagnosis without comparing the tooth in question with adjacent and contralateral teeth. It is best to test the adjacent teeth and contralateral teeth first so that the patient is familiar with the experience of a normal response to cold. Rev PulpitisL Discomfort is experienced when a stimulus such as cold or sweet is applied and goes away within a couple of seconds following the removal of the stimulus. Typical aetiologies may include exposed dentin (dentinal sensitivity), caries or deep restorations. There are no significant radiographic changes in the periapical region of the suspect tooth and the pain experienced is not spontaneous. Following the management of the aetiology (e.g. caries removal plus restoration; covering the exposed dentin), the tooth requires further evaluation to determine whether the “reversible pulpitis” has returned to a normal status. Although dentinal sensitivity per se is not an inflammatory process, all of the symptoms of this entity mimic those of a reversible pulpitis. Sym Irrev Pulpitis: . Sometimes the pain may be accentuated by postural changes such as lying down or bending over and over-the-counter analgesics are typically ineffective. Common aetiologies may include deep caries, extensive restorations, or fractures exposing the pulpal tissues. Teeth with symptomatic irreversible pulpitis may be difficult to diagnose because the inflammation has not yet reached the periapical tissues, thus resulting in no pain or discomfort to percussion. In such cases, dental history and thermal testing are the primary tools for assessing pulpal status. Could result in irreversible pulpitis if cause not removed
- The pulpal nerve fibers, A-delta (which respond to cold and the EPT) and C-fibers (which respond to heat and elicit the nerve response when a patient reports spontaneous tooth pain), are nociceptors. Nociceptors are sensory receptors that respond to stimuli by sending nerve signals to the brain. This stimulus can cause the perception of pain in an individual.9 By objectively testing the pulpal nerve fibers, a dentist can best determine pulpal status. Diagnostic terminology approved by the American Association of Endodontists and the American Board of Endodontics5-7 Pulpal diagnoses9-\ One cannot arrive at a probable diagnosis without comparing the tooth in question with adjacent and contralateral teeth. It is best to test the adjacent teeth and contralateral teeth first so that the patient is familiar with the experience of a normal response to cold. Rev PulpitisL Discomfort is experienced when a stimulus such as cold or sweet is applied and goes away within a couple of seconds following the removal of the stimulus. Typical aetiologies may include exposed dentin (dentinal sensitivity), caries or deep restorations. There are no significant radiographic changes in the periapical region of the suspect tooth and the pain experienced is not spontaneous. Following the management of the aetiology (e.g. caries removal plus restoration; covering the exposed dentin), the tooth requires further evaluation to determine whether the “reversible pulpitis” has returned to a normal status. Although dentinal sensitivity per se is not an inflammatory process, all of the symptoms of this entity mimic those of a reversible pulpitis. Sym Irrev Pulpitis: . Sometimes the pain may be accentuated by postural changes such as lying down or bending over and over-the-counter analgesics are typically ineffective. Common aetiologies may include deep caries, extensive restorations, or fractures exposing the pulpal tissues. Teeth with symptomatic irreversible pulpitis may be difficult to diagnose because the inflammation has not yet reached the periapical tissues, thus resulting in no pain or discomfort to percussion. In such cases, dental history and thermal testing are the primary tools for assessing pulpal status.
- For endodontic diagnostic purposes, the depth of caries past or present is an important radiographic indicator of teeth with pulpal pathosis. While carious exposures of the pulp cannot be seen radiographically, gross caries that approximates the radiographic outline of the pulp chamber is frequently evident even in the absence of symptoms (Fig. 3-5, A). Pulp exposure would be a logical expectation following excavation of such lesions, and root canal treatment of this tooth would be a necessary part of the treatment plan. . Fig. 3-6, A represents a symptomatic tooth with a carious lesion in close proximity to the mesial pulp horn. Excavation revealed a gross carious exposure and necrotic pulp. Root canal treatment was indicated
- For endodontic diagnostic purposes, the depth of caries past or present is an important radiographic indicator of teeth with pulpal pathosis. While carious exposures of the pulp cannot be seen radiographically, gross caries that approximates the radiographic outline of the pulp chamber is frequently evident even in the absence of symptoms (Fig. 3-5, A). Pulp exposure would be a logical expectation following excavation of such lesions, and root canal treatment of this tooth would be a necessary part of the treatment plan. . Fig. 3-6, A represents a symptomatic tooth with a carious lesion in close proximity to the mesial pulp horn. Excavation revealed a gross carious exposure and necrotic pulp. Root canal treatment was indicated
- For endodontic diagnostic purposes, the depth of caries past or present is an important radiographic indicator of teeth with pulpal pathosis. While carious exposures of the pulp cannot be seen radiographically, gross caries that approximates the radiographic outline of the pulp chamber is frequently evident even in the absence of symptoms (Fig. 3-5, A). Pulp exposure would be a logical expectation following excavation of such lesions, and root canal treatment of this tooth would be a necessary part of the treatment plan. . Fig. 3-6, A represents a symptomatic tooth with a carious lesion in close proximity to the mesial pulp horn. Excavation revealed a gross carious exposure and necrotic pulp. Root canal treatment was indicated
- Radiographic Changes Associated With Pulpal Necrosis in Periapical Tissues The only pulpal conditions that cause periapical pathosis are (see Chapter 1). At the time of onset of apical inflammation, there may be no changes on a radiograph, yet the tooth will often be acutely tender to percussion, with radiographic changes usually following within a few days. The radiographic lesion which appears is the result of bone resorption caused by the necrotic pulpal tissue and bacteria emanating from the apical foramen. Many lesions develop slowly over a relatively long period of time. Even in cases of acute apical infection without a preexisting lesion, a radiographic lesion may not become evident for as long as 10 days.3,4 The earliest change will be observed as a widening of the periodontal ligament space in the region of the apical foramen. This can sometimes be subtle and difficult to distinguish from the variation seen in the normal apical anatomy. For this reason, the radiograph alone is insufficient to make a final diagnosis. A history of symptoms would be very important, and sensibility testing and the other forms of clinical evaluation would have to be done.
- (or a “pulp polyp”) Nevertheless, because the inflammation is irreversible, tooth extraction or endodontic therapy is required.
- . Diagnosis: Pulp necrosis; symptomatic apical periodontitis with condensing osteitis
- Diagnosis: Symptomatic irreversible pulpitis; normal apical tissues. Non-surgical endodontic treatment is indicated; access is to be repaired with a permanent restoration. Note that the maxillary second premolar has severe distal caries; following evaluation, the tooth was diagnosed with symptomatic irreversible pulpitis (hypersensitive to cold, lingering eight seconds); symptomatic apical periodontitis (pain to percussion).
- Diagnosis: reversible pulpitis; normal apical tissues. Treatment would be excavation of the caries followed by placement of a permanent restoration. If the pulp is exposed, treatment would be non-surgical endodontic treatment followed by a permanent restoration such as a crownin the region.
- Diagnosis: pulp necrosis; asymptomatic apical periodontitis. Treatment is non-surgical endodontic treatment followed by bleaching and permanent restoration
- Diagnosis: pulp necrosis; chronic apical abscess. Treatment is crown removal, non-surgical endodontic treatment and placement of a new crown.
- . Diagnosis: previously treated; symptomatic apical periodontitis. Treatment is non-surgical endodontic retreatment followed by permanent restoration of the access cavity. Fig. 4 Fig. 5 | CE article diagnosis 14 roots 1 2016
- . Diagnosis: pulp necrosis; asymptomatic apical periodontitis. Treatment is nonsurgical endodontic treatment and placement of a permanent restoration.
- With proper integration of clinical and radiographic factors,, the wise and prudent clinician should be able to assess both the process and completed treatment.