Clinical Endodontic Diagnosis
Clinical Endodontic Diagnosis
Robert S. Roda DDS MS
Basic Principles of Endodontics
•Clean, shape and obturate
the root canal systems
•Restore the tooth and re-establish the occlusion
How to Achieve Endodontic Success
•Accurate diagnosis
•Good access
•Thorough cleaning and shaping
•Effective obturation
•Quality restoration
Clinical Endodontic Diagnosis
“There may be different ways of treating a disease, however there can be but one correct diagnosis”
Morton Amsterdam 1974
Diagnostic Objectives
•Reproduce the Chief Complaint
•Determine the Cause
•Eliminate the Cause
Case #1
•The Patient
–28 y.o. female
–Caucasian
–Office worker
–She is obviously in pain
–She is holding a cup of ice water
–She doesn’t look as if she’s slept well.
–What’s going on with this patient?
•Subjective Information
•Objective Findings
•Assessment
•Plan of Treatment
History
•Chief Complaint
–“What problem can I help you with, today?”
(Write the response in the chart under chief complaint)
–“I have a toothache.”
History
Medical History Form
•Completed by patient
•Signed and dated
•Reviewed completely
•Follow-up questions
•Highlight significant conditions
Case #1 - History
•Medical History
–Generally good health
–Had rheumatic fever as a child
–Allergic to pennicillin
S.O.A.P.
•Subjective Information
–History of Pain
–Stimulus of Pain
–Severity of Pain
–Frequency of Pain
–Duration of Pain
–Location of Pain
–Spontaneity of Pain
Subjective Information
•History of the pain
–When did it start?
–Was the pain related to a specific experience?
•Recent dental treatment
•Trauma
•No specific incident
•Stimulus of the pain
–Cold / Heat
–Biting / Chewing / Touching / Pressure
–Pushing on the gums
–No stimulus
•Severity of the pain
–Scale of 1 to 10
–1 = no pain
–10 = worst pain imaginable
–Subjective patient judgment
•Frequency of the pain
–Intermittent or continuous?
–How often do episodes occur?
–Related to some stimulus?
- Duration of the pain
–How long does it persist after removing the stimulus?
•0 – 30 seconds
•> 30 seconds
–Never stops
•Location of the pain
–Localized to one tooth
–Poorly localized to one quadrant
–Poorly localized to one side of the face
–Poorly localized to both sides of the midline
•Spontaneity of the pain
–Spontaneous
•No stimulus related to it
•Wakes patient up at night
–Non-spontaneous
•Always needs a stimulus
•Does the stimulus always cause the pain?
•Nature of the pain
–Throbbing, burning, shooting, dull, sharp
–Very subjective descriptors
Case #1
•Subjective Information
–Pain started on it’s own three days ago - worsening
–Pain is a spontaneous, constant throbbing
–Pain worsens when ingesting hot substances, lingers
–Pain is relieved by cold
–Pain is slightly worsened by biting
–Pain feels like 9 out of 10 - wakes patient up at night
•Document Everything!
S.O.A.P.
•Objective Findings
–Clinical Examination
•Extraoral
•Intraoral
–Radiographic Assessment
–Comparative Testing
–Document Everything!
•Objective Findings
–Clinical Examination
–Radiographic Assessment
–Comparative Testing
•Clinical Examination
•Visual Exam / OCS
• Palpation
• Percussion
• Presence of a Sinus Tract / Swelling
• Caries
• Tooth Fractures
• Fractured or Extensive Restorations
• Periodontal Disease / Probing / Mobility
• Exposed Dentin
• Wear Facets
S.O.A.P.
•Radiographic Assessment
•Buccal Object Rule
Case #1
•Radiographic Assessment
Clinical Tips
•Images
–Must be current
–Must be complete
•Palpation
–Get patient accustomed to “normal”
–Work towards suspect tooth
•Percussion
–Start with uninvolved teeth
•Perio probe – What is WNL?
•Mobility
–Slight - Moderate – Extensive
–Grade I, II, III (vertical)
•Objective Findings
–Comparative Testing
•Thermal Tests
–Cold (H2O, CO2, Endo Ice)
–Heat (Warm Gutta Percha)
•Bite Test
•Electric Pulp Test
•Transillumination
•Anesthetic Test
–Injection
–Topical
•Test Cavity
Clinical Tips
•Cold
–Blowing air is inaccurate
–Use Endo Ice, ice stick, or CO2 snow
•Heat
–Use dab of petroleum jelly to keep gutta percha from sticking to tooth
•Anesthetic Test – may anesthetize adjacent teeth
•Cavity Test – patient reluctance
S.O.A.P.
•Assessment
–Pulpal Diagnosis
–Periradicular Diagnosis
–Non-Endodontic Pathology
•Pulpal Diagnosis
Reversible Pulpitis - Non-lingering (Thermal tests) Not spontaneous.
Usually does not require RCT
Irreversible Pulpitis (symptomatic) – Spontaneous pain. Lingers (after stimulus or thermal tests). Usually severe pain
Usually requires RCT
Irreversible Pulpitis (asymptomatic) – no clinical symptoms but irreversible pulpal inflammation is produced by caries, caries excavation, trauma, etc.
Usually requires RCT
Pulp Necrosis - No Response to thermal or electrical stimuli
Usually requires RCT
Previous Root Canal Therapy –previously completed root canal (canals are obturated)
Usually requires RCT if disease is present or likely to develop
Previously Initiated Therapy - previous pulpotomy/pulpectomy where treatment is not complete, but the canal may contain intracanal medicaments
•Periradicular Diagnosis
Normal Apical Tissues
Symptomatic Apical Periodontitis - pain to biting and percussion (sometimes severe). May or may not have an apical radiolucency
Asymptomatic Apical Periodontitis - Cannot elicit pain or altered sensation, apical radiolucency present
Acute Apical Abscess - Localized Swelling, pain and pus formation associated with a necrotic and infected pulp. Fever, lymphadenopathy, and periapical radiolucency may or may not be present
Chronic Apical Abscess - Inflammatory reaction to pulpal necrosis and inflammation characterized by mild or no symptoms and pus draining from a sinus tract.
Cellulitis - Extraoral spread of infection. Dangerous – treat aggressively
•Non-Endodontic Pathology
–Acute Periodontal Abcess
–Vertical Root Fracture
–Acute / Chronic Sinusitis
–TMD / MPD (incl. Occlusal Trauma)
–Neuropathic Pain
–Vascular Pain
–Atypical Facial Pain