BDS 11130 Diagnosis of Pulp and Periapical Injuries PDF

Diagnosis Of Pulp And Periapical Injuries BDS 11130 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1. To detail the history taking process to reach diagnosis 2. To give an overview of odontogenic and non-odontogenic pain 3. To explain the pulp and periapical injuries classi...

Diagnosis Of Pulp And Periapical Injuries BDS 11130 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1. To detail the history taking process to reach diagnosis 2. To give an overview of odontogenic and non-odontogenic pain 3. To explain the pulp and periapical injuries classification through factors affecting periodontal surgery results Objectives: On completion of this lecture, the student should have: 1. An understanding of signs and symptoms of different pulp and periapical injuries 2. An understanding of different types of pulp and periapical injuries Diagnosis is the art and science of detecting and distinguishing deviations from health its cause and nature. The art of using scientific knowledge to identify disease processes and to distinguish one disease from another The process of making a diagnosis can be divided into five stages: Reasons for seeking advice Symptoms and history Objective clinical tests Differential diagnosis Definitive diagnosis Differential diagnosis in endodontics requires: knowledge Skills Ability to interpret and interact with a patient Diagnostic steps include I) Patient information: 1) Medical history 2) Past dental history 3) Chief complaint 4) History of Present Dental Problem II) Clinical examination: A) Extraoral examination B) Intraoral examination 1) Soft tissue examination 2) Palpation 3) Periodontal examination 4) Percussion test 5) Mobility C) Pulp testing 1) Sensitivity test 2) Vitality test III) Radiographic examination and interpretation I) Patient information: 1) Medical history: Although there are no systemic conditions contraindicates conventional endodontic therapy, However the medical history enables the clinician to determine the need for Medical consultation Premedication of the patient Choice of analgesics & antibiotics The most convenient way of recording medical history is to use a checklist that is kept in the patient’s file No Have you had rheumatic fever or a heart murmur? Have you had heart trouble or high blood pressure? Do you have antibiotic cover for dental treatment? Do you tend to bleed excessively or bruise easily? Do you suffer from asthma, TB, bronchitis or any other chest conditions? Do you suffer from renal (kidney) disease? Have you had liver disease (jaundice or hepatitis)? Do you suffer from epilepsy? Do you have any allergies to medicines or latex? Are you pregnant? Have you ever had depression or mental illness? Are you currently taking any medicine? Are you currently receiving treatment from you General Practitioner or any other specialist? Have you ever been admitted to hospital? Do you smoke? If so how many and how long? Do you drink alcohol? If so how many units per week? Do you have any other illness we should know about? Yes Details I) Patient information: 2) Past dental history: The type & number of past dental treatment should reveal the degree of sophistication of the previous therapy & helps in the evaluation of the expectation of the patient. I) Patient information: 3) Chief complaint Listen carefully to the patients’ explanation of their condition and use the patients’ own words to record it. Patients’ presenting complaints and anxieties Primary (actual) Secondary (fear of) Pain (spontaneous or stimulated by eating or drinking) Anxiety about 1- Disease and its effects 2- Treatment 3- Cost/loss of earnings 4- Appearance Cannot eat/drink (cannot bite, take hot or cold) Swelling Discoloured tooth Broken tooth/filling Tooth/gum does not feel right/feels different Bad odour/taste I) Patient information: 4) History of Present Dental Problem Careful questioning of the patient must be conducted to evaluate the problem completely. It is divided into five basic directions of questioning: Localization: “Can you point to the offending tooth?” Commencement: “When did the symptoms first occur?” Intensity: “How intense is the pain?” Provocation and attenuation: “What produces or reduces the symptoms?” Duration: “Do the symptoms subside shortly, or do they linger after they are provoked?” ENDODONTIC KEY WORDS II) Clinical examination: A) Extraoral examination The clinician should observe patients as they enter the operatory to observe: 1- Physical limitations 2- Signs of facial asymmetry Any facial swelling should be noted Facial swelling is best seen from above the patient Ease of oral access particularly to the posterior part of the mouth Access assessed with two fingers II) Clinical examination: B) Intraoral examination 1) Soft tissue examination Soft tissues, consisting of the cheek mucosa, tongue, floor of mouth, palate, sulcular fold and those overlying the alveolus Soft tissues should wiped with gauze & examined for Signs of inflammation Sinus tract openings Induration Swellings Fibroepithelial growth Ulcers or discoloration II) Clinical examination: B) Intraoral examination 2) Palpation The buccal/labial and palatal/lingual mucosa are palpated by light finger pressure in a rolling motion by index finger Differentiate normal landmarks (bony exostosis) from pathological intraoral swellings Induration, fluctuation or egg shell crackling of intraoral swellings II) Clinical examination: B) Intraoral examination 3) Periodontal examination A general periodontal examination should be performed to characterize the periodontal status as part of the overall treatment plan Root fractures Localized Iatrogenic perforations Loss of attachment Generalized Periodontal disease II) Clinical examination: B) Intraoral examination 4) Percussion test Teeth are percussed in an axial and buccal direction by the forefinger or the end of a mirror handle Tenderness to gentle percussion Inflammation of the periodontal ligament of pulpal or periodontal origin II) Clinical examination: B) Intraoral examination 5) Mobility test To detect the integrity of attachment apparatus ➢ Pressure is applied with 2 handles of 2 instruments in a facial-lingual direction ➢ The amount of movement is judged in relation to an adjacent tooth Miller classification (tooth mobility) Class I: Less than 1 mm in the buccolingual or mesiodistal direction Class II: 1 mm or more in the buccolingual or mesiodistal direction No mobility in the occlusoapical direction (vertical mobility) Class III: 1 mm or more in the buccolingual or mesiodistal direction Mobility in the occlusoapical direction is also present II) Clinical examination: C) Pulp testing 1) Sensitivity tests I) Thermal tests a) Cold Test b) Heat Test II) Electric pulp test (EPT) 2) Vitality tests I) Laser Doppler Flowmetry (LDF) II) Pulse oximetry II) Clinical examination: C) Pulp testing 1) Sensitivity tests ➢ Sensitivity tests assess the neural response ➢ Explanation should be given to the patient as anxious patient may give false positive response. ➢ Adjacent tooth, considered healthy, should be tested first; this will act as the control II) Clinical examination: C) Pulp testing 1) Sensitivity tests I) Thermal tests a) Cold test Contraction of the dentinal fluid Hydrodynamic forces Ethyl chloride is sprayed on a small cotton pellet and applied to the tooth. Stimulation of A-delta nerve fibres Sharp sensation, lasts for a few seconds Tooth isolated with rubber dam and bathed with cold water II) Clinical examination: C) Pulp testing 1) Sensitivity tests I) Thermal tests b) Heat test Tooth surface coated with petroleum jelly Application of hot gutta-percha stick Tooth isolated with rubber dam and bathed with hot water Prolonged application of heat can result in stimulation of C-fibres, resulting in lingering pain (5 seconds) Cold tests appear to be more effective in assessing nerve status than heat tests. Response to thermal tests Pain subsides after removal of the stimulus Normal Strong momentary (1-2 sec) after removal of the stimulus Reversible Pulpitis Strong painful response that lingers Irreversible pulpitis No response Necrotic Recent trauma Excessive calcification II) Clinical examination: C) Pulp testing 1) Sensitivity tests II) Electric pulp tests The electric pulp tester (EPT) delivers a graduated increase in electric current to excite a response from the A-delta nerve fibres Tooth to be assessed is isolated & dried Tip of the probe is coated with a conducting medium (toothpaste) Probe of the EPT should be placed adjacent to the pulp horn When sensation is elicited, the patient is advised to signal to the clinician Obtaining a positive response depends on: 1- Position of the probe on the tooth 2- Thickness of the enamel and dentine. Response to EPT Tingling or warm sensation Normal Pain disappears after removal of the stimulus Reversible pulpitis Pain lingers Irreversible pulpitis Delayed Chronic No response Necrotic Limitations of EPT False –ve response of EPT False +ve response of EPT Recently erupted tooth Partial necrosis Recently traumatized tooth Liquefaction necrosis Pulp calcification Tooth is not dry Undermined enamel Electrode placed near a large metalic restoration II) Clinical examination: C) Pulp testing 2) Vitality tests Laser Doppler Flowmetry (LDF) Measures the blood flow Pulse Oximetry Measures the oxygen concentration in the blood and the pulse rate Vitality tests III) Radiographic examination and interpretation Radiographic examination Preoperative During Operation Post operative I) Preoperative: 1- Size of the pulp chamber 2-Number of roots & root canals (Fast break) 3- Curvature of roots & root canals 4- Size & character of the periapical lesions II) During operation: 1- Working length determination. 2- Any obstruction during work. 3- Verification of the master cone. III) Post operative: IV) Follow-up & recall: Limitations of x-ray: 1) A 2 dimensional image for a 3 dimensional object. 2) It is only an image (cannot identify disease). 3) Pulp condition & soft tissue changes cannot be detected. 4) Too dark or too light image. 5) Too long or too short image 6) Lesions of the medullar bone are likely to go undetected until resorption is considerable Shift technique (SLOB) Change In horizontal angulation Conventional films versus digital image recording: 1- Instant availability 2- Secure storage and archiving of the digital data. 3- The images can be accessed from different computers in a network Cone beam CT: Detects: 1- Endodontic lesions before they become visible on conventional radiographs 2- Missed canal 3- Cervical resorption Medical history Past dental history 1- Patient information Chief complaint Definition of diagnosis Diagnostic steps History of present dental problem 2- Clinical examination Extraoral Intraoral 3- Radiographic examination Pulp testing Aims: The educational aims of this lecture are: 1. To detail the history taking process to reach diagnosis 2. To give an overview of odontogenic and non-odontogenic pain 3. To explain the pulp and periapical injuries classification through factors affecting periodontal surgery results Objectives: On completion of this lecture, the student should have: 1. An understanding of signs and symptoms of different pulp and periapical injuries 2. An understanding of different types of pulp and periapical injuries Reading material: Students are advised to read details at: 1. Cohen`s pathways of the pulp, 11th edition, 2016, Kenneth M. Hargreaves and Louis H. Berman. (chapter 1) 2. Endodontic science (two volumes), 2nd edition, 2009, Carlos Estrela. (chapters 4, 5, 6 and 11) 3. Problems in endodontics, Etiology, diagnosis and treatment, 2009, Michael Hulsmann and Edgar Schafer. (chapter 1) 4. Endodontology, an integrated biological and clinical view, 2013, Domenico Ricucci and Jose F. Siqueira Jr. 5. Clinical endodontics, 3rd edition, 2009, Leif Tronstad. (chapters 3 and 4) Thank You