Endo Exam and Testing.pdf

Endodontic Exam and Testing Endodontic Diagnosis Pulpal o Status of the nerve tissue (Pulp) o “C” nerve fibers - dull spontaneous ache o “A” nerve fibers - sharp acute intense pain o Detects temperature and sharpness Periapical o Status of the tissues surrounding the apex o Proprioceptive (pressure...

Endodontic Exam and Testing Endodontic Diagnosis Pulpal o Status of the nerve tissue (Pulp) o “C” nerve fibers - dull spontaneous ache o “A” nerve fibers - sharp acute intense pain o Detects temperature and sharpness Periapical o Status of the tissues surrounding the apex o Proprioceptive (pressure sensing) nerve fibers o Detects chewing pressure and percussion Diagnostic Exams Tx cant be determined w/o correct diagnosis o If you don’t know the diagnosis after reviewing the hx, you haven’t taken enough hx o Physical exam verifies diagnosis Order of diagnostic exam: o Subjective o Objective o Assessment/Appraisal o Plan Subjective Chief Complaint (CC) o What the patient tells you in “Their Own Words” Subjective findings are what the patient is telling you (may not be accurate) o Usually a one sentence answer Must learn to ask the right questions o Every question should have a purpose Must address the CC even though you may see other issues Med Hx Should be reviewed by Dentist on every visit o Updated by pt every visit o Pt to fill out new med hx if it has been over a year Drug allergies Medical conditions that can mimic odontogenic pain: o TB § Can cause enlarged lymph nodes that mimic lymph node enlargement due to odontogenic origin o Uncontrolled Diabetes Mellitus § May exhibit recurrent abscesses which are not dental in origin o Iron deficiency anemia, pernicious anemia and leukemia § Exhibit paresthesia of soft tissue o Sickle Cell § Cause bone pain and loss of trabecular bone pattern § Mimics odontogenic pain and bone loss of Endodontic origin o Multiple Myeloma § Can cause unexplained mobility of teeth (Floating Tooth) o Radiation therapy § Increased sensitivity of teeth and osteoradionecrosis o Trigeminal neuralgia, Referred pain from cardiac angina, Multiple sclerosis § Can mimic dental pain Sinusitis o Acute maxillary sinusitis Extreme cold pain § Posterior quadrant mimic tooth pain Percusses w pain across affected arch § Teeth may be extremely sensitive to cold and percussion Medical history (developing data) o Endodontic treatment is not contraindicated with most medical conditions. The only systemic contraindications to endodontic therapy are uncontrolled diabetes or a recent myocardial infarction (MI) (within the past 6 months) o The patient’s medical history enables the clinician to determine the need for a medical consultation or premedication of the patient Dental Hx Chronology of events leading up to the CC Include any past and present symptoms Recent dental work 5 basic directions of questioning o Localization – where o Commencement - when did is start o Intensity - pain scale 1-10 o Provocation/Attenuation - what produces or reduces symptoms o Duration Endodontic Exam and Testing Intraoral diagnostic tests o Help define the pain by evoking reproducible symptoms that characterize the chief complaint o Help provide an assessment of normal responses for comparison with abnormal responses Dentist should include adequate controls for test procedures Several adjacent, opposing, and contra-lateral teeth should be tested before the tooth in question to establish the patients normal range of response Dental Hx o Chief complaint § “Can you tell me about your problem?”—as expressed in the patient’s words § The dentist should paraphrase the patient’s responses to verify them Location o The site or sites where symptoms are perceived o “Could you point to the tooth that hurts or swells?”—the patient is asked to indicate the location by pointing to it directly with one finger Triage of patient with pain o Orofacial pain can be the clinical manifestation of various diseases involving the head and neck region. o The cause must be differentiated between odontogenic and nonodontogenic § Numerous orofacial diseases mimic endodontic pain (may produce sensory misperception as a result of overlapping between the sensory fibers of the trigeminal nerve) § Characteristics of nonodontogenic involvement (not all apply to all cases) — Episodic pain with pain-free remissions — Trigger points — Pain travels and crosses the midline of the face — Pain that surfaces with increasing mental stress — Pain that is seasonal or cyclic — Paresthesia The accuracy of the patient’s description of pain depends on whether the inflammatory state is limited to the pulp tissue only o If the inflammation has not reached the PDL, it may be difficult for the patient to localize the pain because the pulp contains sensory fibers that transmit only pain, not location o The PDL contains proprioceptive sensory fibers. When the inflammatory process extends beyond the apex, it is easier for the patient to identify the source of the pain. (Percussion test can be used.) Referred pain o Pain can also be referred to the adjacent teeth or in the opposing quadrant o It is rare for odontogenic pain to cross the midline of the head o Referred pain may also be ipsilaterally referred to the preauricular area, down the neck, or up to the temple, especially for the posterior teeth o In posterior molars, pain can o ten be referred to the opposing quadrant or to other teeth in the same quadrant o Maxillary molars often refer pain to the zygomatic, parietal, and occipital regions of the head, whereas lower molars frequently refer pain to the ear, angle of the jaw, or posterior regions of the neck. Chronology o “When did you first notice this?”—inception o The patient may be aware of the history of dental procedures or trauma, clinical course, and temporal pattern of the symptoms § Mode—is the onset of symptoms spontaneous or provoked (i.e., sudden or gradual)? If symptoms can be stimulated, are they immediate or delayed? § Periodicity—do the symptoms have a temporal pattern (i.e., sporadic or occasional)? § Frequency—have the symptoms persisted since they began, or are they intermittent? “How often does this pain occur?” § Duration—how long do symptoms last when they occur (i.e., momentary or lingering)? Quality of pain o How the patient describes the complaint § Bony origin—dull, gnawing, or aching § Vascular response to tissue inflammation— throbbing, pounding, or pulsating § Pathosis of nerve root complexes, sensory ganglia, or peripheral innervation (irreversible pulpitis or trigeminal neuralgia)—sharp, electrical, recurrent, or stabbing § Pulpal and apical pathoses—aching, pulsing, throbbing, dull, gnawing, radiating, flashing, stabbing, or jolting pain. Intensity and severity of symptoms o Quantify pain by assigning the pain a degree of 0 (none) to 10 (most severe) Affecting factors—stimulated or spontaneous “Does the pain ever occur without provocation?” Provoking factors o “Does heat, cold, biting, or chewing cause pain?” o The dental pain may be exacerbated by lying down or by bending over. This change increases blood pressure to the head, which increases pressure on the inflamed, confined pulp Attenuating factors o “Does anything relieve the pain?” o “Does drinking warm or cold liquids relieve pain?” o “Does lying down or sitting up relieve pain?” Disposition o How has the pain changed since it started—worse, dissipated, eliminated Supplemental history o Past facts and current symptoms characterizing the difficult diagnosis § It might be necessary to wait a while for vague symptoms to localize § This conservative approach is often necessary in pulpal pathosis confined to the root canal space, which can refer pain to other teeth or to nondental sites Objective What you as the doctor clinically see and your findings o What does the extra oral exam show? Swelling, Redness, tender to palpate etc o What does the x-ray show o Intraoral exam findings o All test findings - percussion, thermal, observation, palpation, periodontal probing and pt’s response o Record normal as well as abnormal Examination and Testing Extraoral Exam o Starts when you walk in and meet the patient § Look for asymmetries and swelling, redness and demeanor of patient o Palpation of submandibular and cervical lymph nodes § Hard, tender and enlarged may indicate that infection has moved from localized to more systemic infection o Red, swollen under or around one eye o Large firm red swelling under chin into neck § Ludwig’s Angina -> Dangerous External sinus tract o May have been getting treatment for a stoma (opening) that never heals o Will generally heal and close once offending tooth is treated Extraoral facial swelling is usually Endodontics in origin o Diffuse facial swelling from a periodontal abscess is rare Canine space infection Canine-space o Loss of definition in the nasolabial fold to swollen red eye infections can cause o Long rooted maxillary central incisors can cause this swelling, more likely the nasiolabial fold to to cause the upper lip to be swollen disappear Buccal space infection Maxilla o Extraoral swelling in posterior cheek o Usually from the buccal roots of maxillary premolar and molars Buccal space infection Mandibular o From mandibular premolar and mandibular 1st molar o 2nd and 3rd molars may also be the cause but infections with these two teeth are just as likely to exit the lingual Reason for the locations o Roots on maxillary lie superior to the attachment of the buccinator muscle o Roots on the mandibular lie inferior to the attachment of the buccinator muscle Extraoral swelling assc w mandibular incisors will swell in the submittal or submandibular spaces Submandibular space swelling o Infections assc w any mandibular teeth that exit the alveolar bone on the lingual and are inferior to the mylohyoid muscle attachment Intraoral Exam Soft Tissue Exam o Should be routine o Look for discoloration, abnormal textures o Retract and look under and on sides of tongue o Refer for biopsy if something is suspect Intraoral Swelling o Visualize and palpate to determine if firm, diffuse or fluctuant o In Anterior palate - most frequently from maxillary lateral incisors or maxillary 1st premolar § More than 50% of maxillary lateral incisors deviate in the distal and palatal direction § Swelling in the posterior palate most likely assc with palatal roots of maxillary molars o Severe infections involving the maxillary and mandibular molars can extend into the parapharyngeal space § Causes swelling of the tonsillar and pharyngeal areas § Can be life threatening cutting off the airway Intraoral Sinus Tract Intraoral sinus tract vs fistula: o Sinus tract § Communication directly from source through an opening in the gingiva (stoma) § Sometimes lined with epithelium o Fistula § An abnormal pathway btwn two organs/from one epithelium lined surface to another epithelium lined surface If the patient has an intraoral sinus tract, there will be very little if any pain Pt may not know they had any issue and the sinus tract is found by the dentist on routine exam Sinus Tract Can Aid in Diagnosis Sinus tract will trace to the offending tooth o May have a stoma adjacent to offending tooth or the infection may exit at a distant site o Can confuse your diagnosis if you don’t trace the sinus tract To trace the sinus tract: o Insert a gutta percha point and take an X-ray o The gutta percha will trace to the origin of the abscess Palpation Alveolar hard tissue near apices should be palpated w index finger o If suspicious area present -> palpate opposite side to determine if symmetrical or possibly abnormal o Tender areas -> possible periradicular inflammation § May be endodontic or periodontic in nature Apical inflammation after pulp necrosis can have inflammatory process that burrows through the facial cortical bone and begins to affect the overlying mucoperiosteum Before incipient swelling becomes clinically evident, it may feel tender when shaving/applying makeup Percussion Inflammation around the periapical portion of tooth can be indicated by: o Tenderness to percussion o Tenderness to biting Felt by the proprioceptive nerve fibers around tooth (PDL) Apical inflammation (Apical Periodontitis) can be caused by bacteria from the necrotizing pulp of offending tooth o Must rule out other reasons (ex. “high occlusion” from recent dental tx) Process of percussion: o Use mirror handle to lightly percuss all cusp tips o Can percuss from buccal and lingual too § If pt is very tender, start with just a finger to press o Start w contralateral tooth so the patient knows what “normal” feels like o Percuss adjacent teeth medially and distally to help confirm offending tooth o Repeat several times to verify consistency Percussion tells nothing about the vitality of the pulp NBDE Percussion Percussion test does not indicate the health of the pulp o The sensitivity of the proprioceptive fibers shows inflammation of the apical PDL Positive percussion response = Presence of PDL inflammation, extent of the inflammatory process o Degree of response correlates w degree of inflammation Other factors may also inflame the PDL and yield positive percussion test: o Rapid orthodontic movement of teeth. o A recently placed restoration in hyper-occlusion. o A lateral periodontal abscess. First percussion test should be performed with the clinician’s finger on non-suspect tooth o If the pt is unable to discern -> blunt handle of mouth mirror should be used o Having pt chew on a cotton roll/swab or the reverse end of a low-speed suction straw may help Mobility Increased mobility = compromised periodontal attachment o Tells nothing of tooth vitality Can be a result of: o Acute or chronic trauma o Periodontal disease o Root fractures o Rapid orthodontic movement o Extension of pupal disease into the PDL Mobility can be reversed after offending issue(s) are eliminated Use the Endo of two mirror handles and push buccolingually and occlusally o Any mobility greater than +1 should be considered abnormal o Must compare the mobility to adjacent and surrounding teeth