BDS 11132 Diagnostic Challenges PDF

Diagnostic challenges BDS 11132 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1- To explain how clinical findings might be misdiagnosed 2- To explain how radiographic findings can be misdiagnosed 3- To explain how pulp tests can give true or false readings Objectives: On...

Diagnostic challenges BDS 11132 Date : xx / xx / xxxx Aims: The educational aims of this lecture are: 1- To explain how clinical findings might be misdiagnosed 2- To explain how radiographic findings can be misdiagnosed 3- To explain how pulp tests can give true or false readings Objectives: On completion of this lecture, the student should have: 1- An understanding of the challenges they might face during diagnosing pain or radiographic lesions 2- An understanding of the pulp tests mechanism and what interferes with the readings I- Special tests for difficult clinical situations 1) Trans-illumination test 2) Staining test 3) Bite/cusp loading tests 4) Selective anesthesia test 5) Gutta-percha tracing with a radiograph 6) Cavity test 1) Trans-illumination test ➢ Transmission of a powerful light through teeth will show interproximal caries, cracks, infractions and fractures ➢ The fibreoptic light placed next to the neck of the tooth and moved along its surface ➢ The light will not pass across the fracture line due to reflection so the fracture remains dark 2) Staining test ➢ It may be necessary to remove the restoration in the tooth to better visualize a crack or fracture ➢ Methylene blue dye is painted on the tooth surface with a cotton tip applicator, excess dye may be removed with 70% isopropyl alcohol ➢ The dye will penetrate into cracked areas 3) Bite/cusp loading tests ➢ Used for patients with a suspected cusp, tooth or root fracture presenting with poorly localized pain on biting ➢ The patient is instructed to bite firmly on a cotton roll or a commercially available ‘Tooth Slooth’ ➢ Biting pressure results in the temporary separation of the fractured segments 4) Selective anesthesia test ➢ If symptoms, particularly pain, are poorly localized intraligamental local anaesthetic injection technique starting from the distal sulcus of the most posterior maxillary tooth until the pain disappears ➢ If, after an appropriate interval, the pain persists, the test should be performed similarly in the mandibular quadrant. 5) Gutta-percha tracing with a radiograph ➢ If a patent sinus is present preoperatively, a radiograph may be taken with a size 30 gutta-percha point in place ➢ The point should be inserted into the sinus until resistance or discomfort is encountered and a radiograph taken to track the source and confirm the causative tooth 6) Cavity test Assess the pulp status when all other tests are inconclusive Local anaesthesia is not adminstered Small bur is used with copious irrigation to prepare a small cavity down to dentine Sensitivity Vital tooth No response Lack of vitality Note: A-delta fibres may still be viable in necrotic pulp tissue II- Loupes and operating microscopes ➢ Endodontic procedures are often performed in areas of limited access and reduced visibility ➢ Magnifying binocular loupes and dental operating microscopes provide the combined benefits of magnification & illumination ➢ Facilitate canal orifice location in difficult cases & help to locate crown fractures or cracks III- Anatomical variations in the maxilla and mandible The bone trabeculae have a coarser pattern in the mandible than in the maxilla Nasal fossa Nasal septum Incisive foramen Outline of the nose Radiographic appearance of a mental foramen Inferior dental canal, which may be confused with periradicular lesion Large maxillary antrum, which may be confused with a cyst IV- Cracks and Fractures ➢ The ability to determine the presence of a crack will depend upon the plane of the fracture in relation to the main X-ray beam. ➢ If the beam does not pass through the fracture, it will remain undetected. ➢ The presence of a post-retained restoration in a tooth with a large diffuse lesion involving more than just the apical region should arouse suspicion of a perforation or fracture V- Diagnostic Categories 1- Normal pulp ➢ Asymptomatic ➢ Gives a mild, transitory response to stimulation with thermal or electrical tests ➢ Percussion and palpation do not cause pain 2- Concussed pulp ➢ May not respond to thermal or electrical stimulation for a period of weeks or months 3- Reversible pulpitis ➢ Hot or cold stimuli will cause a quick sharp pain, which subsides within 5-10 seconds ➢ Common causes include caries and coronal leakage ➢ Radiological examination may confirm the presence of caries or a defective restoration 3- Irreversible pulpitis Aching and throbbing Radiate from the maxilla to the mandible or vice versa Patient is unable to locate the affected tooth Pain Occurs at night as lying down increases the intrapulpal pressure Lasts for a few minutes up to several hours (lingers) 5- Pulpal necrosis ➢ Necrosis may occur following irreversible pulpitis or as a result of trauma disrupting the blood supply to the pulp. ➢ Thermal and electrical pulp testing will produce no response In a posterior tooth, the pulp tissue in more than one of the canals may be vital, which makes tests inconclusive. 6- Acute periapical inflammation ➢ Due to an extension of pulpal disease, trauma, a high restoration or endodontic treatment that has been extended beyond the apical foramen ➢ The tooth is very tender to touch ➢ Radiographic change will be minimal, but may show slight widening of the periodontal ligament 7- Acute apical abscess ➢ Implies the presence of purulent exudate around the apex. ➢ Intense throbbing pain and the tooth will not respond to sensitivity tests ➢ The tooth is extremely tender to touch and palpation of the overlying gingiva is painful. ➢ Radiographically, the appearance is similar to acute periapical inflammation. A chronic lesion may flare up into an acute apical abscess in such cases, there will be periapical rarefaction. 8- Chronic apical periodontitis ➢ Long-standing asymptomatic inflammation around the root apex. ➢ Does not respond to sensitivity testing ➢ From time to time, the patient may become aware of the tooth. ➢ Radiolucency is apparent which varies from a widened periodontal ligament to a large area ➢ The pulp will be non-vital 9- Chronic periapical abscess ➢ The tooth is usually symptom-free ➢ It is not responsive to pulp sensitivity tests ➢ Radiologically, there will be a periapical radiolucency ➢ Chronic periapical abscess may be distinguished from chronic apical periodontitis because the former will usually be associated with a draining sinus tract. VI- Odontogenic and non-odontogenic pain ➢ Only two structures serve as sources for primary odontogenic pain: 1- Pulp–dentin complex 2- The periradicular tissues ➢ The warning symptoms of non-odontogenic toothache are as follow: 1- Spontaneous multiple toothaches. 2- Inadequate local dental cause for the pain. 3- Stimulating, burning, non-pulsatile toothaches. 4- Persistent, recurrent toothaches. 5- Local aesthetic blocking of the offending tooth does not eliminate the pain. 6- Failure of the toothache to respond to reasonable dental therapy Sources of non-odontogenic pain 1- Cardiac toothache 2- Myofacial pain 3- Sinus Toothache 4- Neurovascular Toothache 5- Neuropathic Toothache 6- Neoplastic Toothache 7- Psychogenic Toothache 8- Sickle cell disease Sources of non-odontogenic pain 1- Cardiac toothache ➢ Anginal pain may be felt in the lower left jaw ➢ Anesthetizing the lower jaw or providing dental treatment will not reduce the pain 2- Myofacial pain ➢ Pain from masseter, temporalis or anterior digastric muscle ➢ Can be differentiated by palpation of the suspected muscle 3- Sinus Toothache ➢ Infection and inflammation in the maxillary sinus can also present as odontogenic pain ➢ Sensitivity to percussion, mastication, and/or temperature felt in multiple teeth suggests pain of sinus origin ➢ History of respiratory infection or nasal congestion suggests pain of sinus origin Sources of non-odontogenic pain 4- Neurovascular Toothache ➢ Headaches involving the orofacial region may be mistaken as odontogenic pain (misdiagnosed as pulpitis) ➢ History and comprehensive clinical examination provide evidence of non odontogenic cause of pain 5- Neuropathic Toothache ➢ This type of pain is a diagnostic challenge to the clinician as structures innervated by these nerves are painful but appears clinically normal ➢ It is often experienced in a wider area. ➢ Patient reports that pain is felt along the distribution of the nerve involved and is often experienced following stimulation of the trigger points Sources of non-odontogenic pain 6- Neoplastic Toothache ➢ It must be considered when localized soft or hard tissue changes develop in close proximity to odontogenic structures and diagnostic findings are equivocal or negative. 7- Psychogenic Toothache ➢ It involves multiple teeth and pain may jump from one tooth to another ➢ Absence of a physiological factor or a pathological cause and presence of psychological factor gives a clue about the non-odontogenic cause of pain 8- Sickle cell disease ➢ Vaso-occlusive crisis is a common painful complication of sickle cell anemia where blood vessels are obstructed by sickled red blood cells ➢ If it occurs within the dental pulp this will lead to pain within the teeth with absence of any dental pathology VII- Pulpal and periapical pain Pupal pain ➢ Pulpal pain mediated by C-fibers and is dull, aching, or throbbing in nature. ➢ This is in contrast to the quick, short, sharp sensation produced by A-delta fibers that mediate dentinal pain. ➢ When the pulp is irreversibly inflamed the pain is: 1- Sharp throbbing 2- Spontaneous 3- Lingering 4- Increases at night 5- Diffused or referred due to lack of proprioceptive information Periapical pain ➢ Moderate to severe pain ➢ Localized due to mechanoreceptors which are numerous in the periodontal ligament ➢ In the early stages biting on the tooth relieves pain ➢ Later the pain becomes severe throbbing & increases on biting or at night In case of acute pulpitis with apical periodontitis both pulpal & periapical pain will occur & this is considered the most difficult condition to be treated I- Special tests for difficult clinical situations II- Loupes and operating microscopes III- Anatomical variations in the maxilla and mandible IV- Cracks and Fractures V- Diagnostic Categories VI- Odontogenic and non-odontogenic pain VII- Pulpal and periapical pain Aims: The educational aims of this lecture are: 1- To explain how clinical findings might be misdiagnosed 2- To explain how radiographic findings can be misdiagnosed 3- To explain how pulp tests can give true or false readings Objectives: On completion of this lecture, the student should have: 1- An understanding of the challenges they might face during diagnosing pain or radiographic lesions 2- An understanding of the pulp tests mechanism and what interferes with the readings 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. 2. Endodontic science (two volumes), 2nd edition, 2009, Carlos Estrela. 3. Problems in endodontics, Etiology, diagnosis and treatment, 2009, Michael Hulsmann and Edgar Schafer. 4. Endodontology, an integrated biological and clinical view, 2013, Domenico Ricucci and Jose F. Siqueira Jr. 5. Clinical endodontics, 3rd edition, 2009, Leif Tronstad. Thank You