Lecture 1 Endodontic Diagnosis PDF

Lecture 1 ‫ انس فالح مهدي‬.‫د‬.‫أ‬ Endodontic Diagnosis The process of making a diagnosis can be divided into five stages: 1- The patient tells the clinician the reasons for seeking advice. 2- The clini...

Lecture 1 ‫ انس فالح مهدي‬.‫د‬.‫أ‬ Endodontic Diagnosis The process of making a diagnosis can be divided into five stages: 1- The patient tells the clinician the reasons for seeking advice. 2- The clinician questions the patient about the symptoms and history that led to the visit. 3- The clinician performs objective clinical tests. 4- The clinician correlates the objective findings with the subjective details and creates a tentative list of differential diagnoses. 5- The clinician formulates a definitive diagnosis. Information gathered is accumulated by means of an organized and systematic approach that requires considerable clinical judgment. The clinician must be able to approach the problem by crafting what questions to ask the patient and how to ask these pertinent questions. Careful listening is paramount to begin painting the picture that details the patient’s complaint. These subjective findings combined with the results of diagnostic tests provide the critical information needed to establish the diagnosis. Subjective Findings: These can be obtained by questioning patient and not evident by the examiner: Chief complaint: It is a description of the dental problem by the patient. It should be noted by the patient own words. After recording chief complaint, history of present illness is recorded. History of present dental illness: Pain is the main reason for the patient's complain. It ranges from dull to severe which indicates the severity of the problem. It may indicate the source which may be dental or the surrounding structures. Dentist should ask the following questions regarding pain: 1- Quality: Dull, sharp, throbbing, constant 2- Location: Localized, diffuse, referred, radiating 3- Duration: Constant or intermittent lasting for seconds, minutes or hours 4- Onset: Stimulation required, intermittent, spontaneous 5- Initiation factors: Cold, heat, palpation, percussion 6- Relieving factors: Cold, heat, any medications, sleep Medical history: There are no medical conditions which specifically contraindicate endodontic treatment, but there are several which require special care. Scully and Cawson have given a checklist of medical conditions which are needed to be taken a special care. If there is any doubt regarding state of health of patient, consult medical practitioner before initiating endodontic treatment. Objective Findings: These are examinations and tests that should be performed by the clinician to identify the diagnosis: Extraoral examination: Inflammatory changes originated intraorally and observable extraorally may indicate a serious spreading problem. Signs that need to look for are: 1- Physical limitations such as limitation in mouth movement during speaking. 2- Facial asymmetry that result from facial swelling. 3- Lymph nodes involvement 4- Present of skin open sinus tract Visual and palpation examinations of the face and neck are warranted to determine. Palpation allows the clinician to determine whether the swelling is localized or diffuse, firm or fluctuant. These latter findings will play a significant role in determining the appropriate treatment. Sinus tracts of odontogenic origin may also open through the skin of the face. These openings in the skin will generally close once the offending tooth is treated and healing occurs leaving a scar on the skin surface. Figure 1: A, Extraoral sinus tract opening onto the skin in the central chin area. B, Radiograph showing large radiolucency associated with the mandibular incisors. C, A culture is obtained from the drainage of the extraoral sinus tract. D, The healed opening of the extraoral sinus tract 1 month after root canal therapy was completed. Note the slight skin concavity in the area of the healed sinus tract. Intraoral examination The oral vestibules and buccal mucosa should be examined for localized swelling and sinus tract or color changes. The lingual and palatal soft changes should be then checked. Any raised lesions or ulcerations should be documented and, when necessary, evaluated with a biopsy or referral. Teeth should be inspected for a carious lesion, faulty restoration, loss of teeth, presence of deciduous or supernumerary teeth. Intraoral swellings should be visualized and palpated to determine whether they are diffuse or localized and whether they are firm or fluctuant. These swellings may be present in the attached gingiva, alveolar mucosa, mucobuccal fold, palate, or sublingual tissues. Intraoral sinus tracts may be opened in the alveolar mucosa, in the attached gingiva, or through the furcation or gingival crevice. They may exit through either the facial or the lingual tissues depending on the proximity of the root apices to the cortical bone. Tracing the sinus tract will provide objectivity in diagnosing the location of the problematic tooth. To trace the sinus tract a size #25 or #30 gutta-percha cone is threaded into the opening of the sinus tract. The cone should be inserted until resistance is felt. After a periapical radiograph is exposed, the origin of the sinus tract is determined by following the path taken by the gutta- percha cone, as shown in Fig 2. Figure 2: A) Close-up view shows a gutta-percha cone being inserted in the root canal above first premolar. B) Radiograph shows two teeth where a thread is inserted through the first tooth. The first tooth is radiopaque while the second tooth is partially radiolucent. C) Radiograph shows the gutta-percha is seen to be directed to the source of pathosis, the apex of the maxillary first premolar. Palpation: A palpation test is performed by applying firm pressure by the index finger to the mucosa covering the roots and apices and question the patient about any areas that feel unusually sensitive during examination. This can detect the presence of periradicular abnormalities or specific areas that produce painful response to digital pressure. A positive response to palpation may indicate an active periradicular inflammatory process. However, this test does not indicate whether the inflammatory process is of endodontic or periodontal origin. Percussion: it is performed by gentle tapping on the incisal or occlusal surfaces of the accused tooth with a blunt instrument, usually by the back end of a metal instrument handle and compare that with normal tooth. The tooth crown should first be tapped vertically, if sensitivity obtain this could be an indicative for the presence of periapical pathosis. Horizontal tapping should be also performed to differentiate between periapical and lateral periodontal lesion. Mobility: Tooth mobility is directly proportional to the integrity of the attachment apparatus or to the extent of inflammation in the periodontal ligament. Often the mobility reverses to normal after the initiating factors are repaired or eliminated. This test can be done by the back ends of two mirror handles, one on the buccal aspect and one on the lingual aspect of the tooth. Pressure is applied in a facial-lingual direction as well as in a vertical direction and the tooth mobility is scored. Any mobility that exceeds +1mm should be considered abnormal. However, the teeth should be evaluated on the basis of how mobile they are relative to the adjacent and contralateral teeth. Figure 3: Mobility testing of a tooth, using the back ends of two mirror Periodontal evaluation: The periodontal pathology as gingivitis and periodontal pockets may affect the pulp therefore periodontal treatment may be necessary before or with the endodontic treatment. Detailed periodontal probing around suspected teeth may reveal a sulcus within normal limits. However, deeper pocketing will be identified. A narrow defect may be an indication of a root fracture or an endodontic lesion draining through the gingival crevice. This causes an endodontic-periodontal lesion. Analysis of occlusion: It is important to examine suspected teeth for interferences on the retruded arc of closure, intercuspal position and lateral excursions. Interferences in any of these positions could result in a degree of occlusal trauma and institute acute apical periodontitis. Pulp testing Pulp test (pulp sensibility test) is a diagnostic procedure to determine pulp status. It can be performed by applying thermal, electrical, or mechanical stimuli. Objectives of pulp testing: 1- To assess health of pulp based on its qualitative sensory response prior to restorative, endodontic procedures 2- To differentially diagnose periapical pathologies of pulpal or periodontal origin 3- To assess status of pulp as a follow-up after trauma to teeth 4- To check status of tooth especially that has past history of pulp capping or deep restoration 5- To diagnose oral pain whether it is of pulpal or periodontal origin or because of other reason 1- Thermal tests. The baseline or normal response to either cold or hot is a patient’s report that a sensation is felt but disappears immediately upon removal of the thermal stimulus. Abnormal responses include a lack of response to the stimulus which means the tooth is none vital, or intensified pain on placement or after removal of stimuli which mean the tooth is inflamed. The cold or hot stimuli should be place on the middle third of the labial or lingual surface to be more effective. A- Cold testing. It is the most commonly used test for assessing the vitality of pulp. Cold causes contraction of fluid within dentinal tubules, resulting in outward flow of fluid from tubules and thereby pain. This test is used to differentiate between reversible and irreversible pulpitis and identifying necrotic teeth. If a tooth is sensitive to a cold stimulus which subsides after removal of stimulus then the condition is reversible. If the sensitivity takes time more than few seconds then the condition may be irreversible. Teeth with calcified canals need more time for the cold stimulus to reach the pulp. This test is especially useful for patients presenting with porcelain jacket crowns or porcelain- fused-to-metal crowns where no natural tooth surface (or much metal) is accessible. Cold testing may be done by air blast, cold drink, ice stick or ethyl chloride.  Figure 4: Application of cotton pellet saturated with ethyl chloride B- Hot testing. It is most advantageous in the condition where patient’s chief complaint is intense dental pain upon contact with any hot object or liquid. The use of a hot stimulus can help locate symptomatic tooth with necrotic pulp. Heated gutta percha stick or hot water may be used. Disadvantage of using gutta percha stick is that because of high temperature pulpal damage can occur. Heat test should not be done for >5 s because prolonged heat application causes biphasic stimulation of Aδ fibers followed by C fibers, which can result in persistent pain. 2- Electric pulp testing: Electrical pulp tester is a battery operated device (Fig. 5) which acts by generating pulsatile electrical stimuli and stimulation of Aδ nerve fibers. Many factors affect the level of response as enamel thickness, area of probe placement (in the middle third of the labial surface), dentin calcification, restorations and patient’s level of anxiety. False positive and negative results may happen. A newly erupted tooth may give a negative response whereas a traumatised young tooth may not respond to testing. Multirooted teeth give inconclusive readings because there are many roots with different degrees of pulp inflammation in each root canal.  Figure 5: electrical pulp tester Procedure: - Isolate the tooth to avoid any false positive response. The best to do that is by using rubber dam - Apply an electrolyte on the tooth electrode and place it on the facial surface of tooth - Precaution should be taken to avoid it contacting adjacent gingival tissue or metallic restorations to avoid false-positive response. - Confirm the complete circuit by clipping a ground attachment on to the patient’s lip. - Once the circuit is complete, slowly increase the current and ask the patient to point out when the sensation occur. - Each tooth should be tested two to three times and the average reading is noted. If the vitality of a tooth is in question, the pulp tester should be used on the adjacent teeth and the contralateral tooth, as control. Figure 6: Checking vitality of tooth using electric pulp tester. 3- Cavity test Occasionally, as a last resort, an access cavity is cut into dentine without local anaesthesia as an additional way of vitality testing. The sensitivity or the pain felt by the patient indicates pulp vitality. If no pain is felt, indicates the tooth is not vital and endodontic therapy may be carried out. Selective anaesthesia testing Selective anaesthesia can be useful in cases of referred pain to distinguish whether the source of pain is mandibular or maxillary in origin. It is less useful for distinguishing pain from adjacent teeth, as the anaesthetic solution may diffuse laterally. Bite test Bite test helps in identifying a cracked or fractured tooth. This is done if patient complains of pain on mastication. Tooth is sensitive to biting if pulpal necrosis has extended to the periodontal ligament space or if a crack is present in a tooth. This test can be done by asking the patient to bite on a hard object such as cotton roll or wood sticks. Tooth slooth is another commercially available device for bite test. It has a small concave area on its top which is placed in contact with the cusp to be tested. Pain present on biting indicates apical periodontitis, and pain present on release of biting force indicates a cracked tooth. Figure 7: Tooth slooth. Staining and transillumination To determine the presence of a crack in the surface of a tooth, the application of a stain (Methylene blue dye) to the area is often of great assistance. The procedure include: 1- It may be necessary to remove the restoration in the tooth to better visualize a crack or fracture. 2- Painted Methylene blue dye on the tooth surface with a cotton tip applicator. This dye can penetrate into cracked areas. 3- Remove the excess dye with a moist application of 70% isopropyl alcohol. 4- The remaining dye will indicate the possible location of the crack. Also transillumination using a bright fiberoptic light probe to the surface of the tooth may be very helpful in detecting cracks and fracture lines. Procedure include: Directing a high-intensity light directly on the exterior surface of the tooth at the cementum- enamel junction (CEJ) may reveal the extent of the fracture. Teeth with fractures block transilluminated light and appear dark, while the part of the tooth that is proximal to the light source will absorb this light and glow. Although the presence of a fracture may be evident using dyes and transillumination, the full extent of the fracture cannot always be determined by these tests alone. Radiographs The radiographic interpretation of a potential endodontic pathosis is an integral part of endodontic diagnosis and prognosis assessment. However, dentist should not rely solely on radiography to prematurely give a definitive diagnosis without using other diagnostic tests. When not coupled with a proper history and clinical examination and testing, the radiograph alone can lead to a misinterpretation of normality and pathosis (see Fig 7). Figure 7: Radiograph showing what appears to be a mandibular lateral incisor associated with periapical lesion of a nonvital tooth. Although pulp necrosis can be suspected, the tooth tested vital. In this case, the appearance of apical bone loss is secondary to a cementoma. Radiographs do not show early signs of pulpitis as there is no periodontal widening at this stage of pulpal degeneration. Radiographic findings may include the loss of lamina dura (laterally or apically) or a periradicular radiolucency indicative of pulp necrosis. Alternatively, radiographs may show pulp chamber or root canal calcification, which may explain reduced responses to pulp sensitivity testing. This emphasises the need for considering using more than one test. Radiographic examination may also reveal tooth/root resorptive defects. References: 1- Berman L H, Hargreaves K M, Rotstein I. Cohen’s Pathways of the Pulp. Elsevier, 12th ed. 2021. 2- Garg N, Garg A. Textbook of Endodontics. Jaypee Brothers Medical Publishers (P) Ltd, 4th ed. 2019.