Endo 10 - Diagnosis (Dr. Monterio)⭐️

1. Establish chief complaint (subjective findings)

2. Review medical and dental history (subjective findings)

3. clinical exam (objective findings)

4. radiographic exam (objective findings)

5. diagnosis (assessment)

what are the 5 steps in reaching an accurate endo diagnosis?

- Write patients' own words ("I can feel my heart beating in my tooth")

- Listen to your patient!

- Ask why he/she is seeking dental treatment

How should you record the patient's chief complaint?

True

T/F: Most medical conditions do not contraindicate the endodontic treatment but NEVER treat a stranger

Minimal difficulty

What would the difficulty level be here according to the AAE Endodontic Case Difficulty Assessment Form and Guidelines:

- No medical problem (ASA Class 1*)

- No history of anesthesia problems

- Cooperative and compliant

Moderate difficulty

What would the difficulty level be here according to the AAE Endodontic Case Difficulty Assessment Form and Guidelines:

- One or more medical problem (ASA Class 2*)

- Vasoconstrictor intolerance

- Anxious but cooperative

High difficulty

What would the difficulty level be here according to the AAE Endodontic Case Difficulty Assessment Form and Guidelines:

- Complex medical history/serious illness/disability (ASA Classes 3-5*)

- Difficulty achieving anesthesia

- Uncooperative

Every visit

How often is the baseline blood pressure and pulse record?

1. Does your patient present any medical disorder?

2. If so, is he/she compensated? Any recent complications?

3. Does he/she use medication for their systemic disease? Did he/she take it today?

4. Is he/she taking medications to relief their toothache?

5. Does he/she have any allergies?

6. Has he/she eaten in the last 3 hours?

6 components to record in medical history

1. Location (Can you point to the offending tooth?)

2. Commencement (When did the symptoms first occur?)

3. Intensity (How intense is the pain from 0 to 10?)

4. Provocation and attenuation (What produces or reduces the symptoms?)

5. Duration (“Do the symptoms subside shortly, or do they linger after they are provoked?")

The dental history is divided into 5 basic directions of questioning:

sinus tract

This is most likely what?

swelling

This is most likely what?

provisional restorations/exposed dentin

This is most likely what?

crown fracture/exposed dentin

This is most likely what?

caries

This is most likely what?

color alteration

This is most likely what?

d (endo condenser)

Which is not a part of the armamentarium for diagnosis?

a) gauze pad

b) cotton pellet/roll

c) mirror

d) endo condenser

e) cotton pliers

f) explorer (regular and endo)

g) perio probe

h) endo ice

c) Always test the suspicious tooth LAST

All of the following are true when testing the teeth before endo diagnosis EXCEPT:

a) Patient is always the normality and the disease.

b) Test before what is normal to establish a baseline response

c) Always test the suspicious tooth first

d) Don't forget to investigate the opposing arch

e) Remember that these tests are comparison tests

f) Test the adjacent and contra-lateral teeth

adjacent and contra-lateral

Which teeth do you use as a comparison when doing pulp tests?

1. Percussion

2. Palpation

3. Probing

4. Mobility

What are the 4 test to evaluate the APICAL status of a tooth (pathology in the PDL)?

No, it is not an indication

Is testing the surrounding tissue an indication of pulp vitality or sensitivity?

A) Cold test (that is for pulpal diagnosis, not apical status)

All of the following will give you information to reach an apical status diagnosis, EXCEPT:

A) Cold test

B) Percussion test

C) Palpation test

D) Perio probing

palpation test

Which apical status test will help you identify detect swelling + bony expansions?

1. Soft Tissue Exam, palpation of the alveolar hard tissue (buccal and lingual)

2. Apply firm digital pressure to the mucosa covering the roots and apices.

3. Search for sensitive areas, that may indicate inflammatory process.

4. Test the quadrant and compare right side vs. left side

4 steps of palpation apical test

Percussion test

Which apical status test is initiated with a digital pressure then tap the incisal or occlusal surfaces with a blunt end of an instrument?

Percussion test

Which apical status test shows if there is or not inflammation in the periodontal tissue in the apical portion, not pulp vitality?

Percussion test

Once infection/inflammatory process has extended through the apical foramen into the PDL space + apical tissues, pain is localizable with what test?

True

T/F: For the percussion test in posterior teeth, you should test all the cuspids

1. Occlusal premature contacts,

2. Apical disease, trauma

3. Root cracks

Findings from which percussion apical test help differentiate between which 3 conditions

bite test (tooth slooth)/occlusal test (marking paper)

After the percussion test, what is another test you can perform to test all cusps?

1. Valuable information about periapical status

2. The PDL is richly innervated by proprioceptive fibers, which makes it easier to localize where the pain comes from (once the infection/inflammation extended to the apical foramen into the PDL and apical tissue)

What is the importance of percussion in Endodontic Diagnosis?

Periodontal probing

Which apical status test includes the following?

- Measurement of periodontal pocket depth (mesial, middle and distal aspects of both buccal and lingual sides) at least 6 points

- Isolated areas of vertical bone loss indicate endodontic origin

Periodontal probing

With a vertical crack, endo-perio lesion or excess of inter-proximal fillings, which clinical test can allow you to reach this differential diagnosis?

Mobility test

Which apical status test includes the following?

- Compromised periodontal attachment apparatus or the extension of inflammation in the periodontal ligament

- Pressure is applied in a facial-lingual direction and vertical direction and should be scored 0-3

1. Acute or chronic physical trauma

2. Occlusal trauma

3. Parafunctional habits

4. Periodontal disease

5. Root fractures

6. Extension of pulpal disease

Findings from the mobility apical test help differentiate between which conditions

transillumination

Which test can reveal hidden decay or a fractured tooth, used for suspicion of cracks/fracture?

Teeth with fracture block the light, part of the tooth that is proximal to the light source will glow and areas beyond will not have light transmitted

How does the transillumination test work?

staining

Which test can methylene blue dye be used to determine the presence of crack in the surface of the tooth?

1. Cold test

2. Electric Pulp Test (EPT)

What are the 2 sensitivity thermal tests to evaluate the pulpal status (responsiveness of pulpal sensory neurons) of a tooth?

cold test

what test is BEST for a pulpal diagnosis?

False - clean, clear & dry tooth before cold test

T/F: you can administer a cold test whether the mucosa is wet or dry

cold test

Large cotton pellet made of a cotton roll and applied in the mid-facial of the tooth or crown that must beisolated and dry. Always test a normal teeth before. This is known as the ___________

1. sensation but disappears immediately upon removal of the stimulus → normal sensation/baseline response

2. no response → pulp necrosis (previously treated/previously initiated; other findings – trauma/calcification/open apex, etc)

3. lingering/intensification of painful sensation after removal of the stimulus → symptomatic irreversible pulpitis

4. hypersensitivity to the cold but it does not linger → reversible pulpitis

4 responses a pt can report after a cold test

1. Establish a baseline tooth before testing suspicious tooth

2. Ask patient to raise hand when sensation is felt, then remove the stimulus

3. Ask patient to lower hand when sensation ends - count the seconds that the sensation lasts

How do you instruct the patient during a cold test?

Electric Pulp Test (EPT)

What test is used to cross-check when cold test is not reliable and functions by producing a pulsating eletrical stimulus?

toothpaste

What can be used as a conducting medium for EPT?

incisal

For anterior teeth, the EPT probe is located in what third of the crown?

middle

For posterior teeth, the EPT probe is located in what third of the crown?

Electric Pulp Test (EPT)

Which test includes the following?

- Should be applied on the tooth adjacent to a pulp horn

- Tooth isolation is essential

- When the patient feels a tingling or warm it should be removed

When the numeric readings on the EPT differs SIGNIFICANTLY from readings obtained from a control tooth

(However, in most cases, response is scored either present or absent)

When do you suspect the presence of disease during EPT?

necrotic pulp

If you reach a max. reading on EPT, what is the probable diagnosis?

Thermal

What type of test is a cold test?

Electric

What type of test is EPT?

a-delta

What nerve fiber do both cold + EPT target?

Yes

Can a cold test be done on a restoration/crown?

No - only tooth structure, but can be done on crown for cold test

Can an EPT test be done on a restoration/crown?

No

Are either of the cold-test or EPT reliable on trauma/immature teeth?

cold

Which pulp test causes osmotic changes inside the dentinal tubules?

Buccal

What tooth surface is the EPT test used on?

EPT

Which pulp test causes ionic changes inside the dentinal tubules?

1. Hot instrument

2. Instrument friction

3. Gutta percha (Use lubricant to keep GP from sticking to tooth)

We perform heat test only when pt complains of pain when hot. What are 3 ways we can administer a heat test?

C fibers

What nerve fiber does the heat test target?

pulp stones

ID the abnormality in the radiograph:

Cavity test

Which test?

- It's an invasive irreversible test.

- Only used when all other test methods are inconclusive.

- Patient is not anesthetized to perform this procedure.

- If the patient reports pain, the procedure is terminated and the tooth is restored.

- If no sensation is felt, RCT is indicated.

Selective anesthesia

Which test?

- When pulp testing is inconclusive and patient does not know if pain comes from maxilla or mandible.

- The injection is administered to the most posterior tooth in the quadrant of the arch that may be suspected, starting from the distal sulcus.

- The anesthesia is administered in an anterior direction, one tooth at a time.

1 PA/ 1BW ( for posterior teeth)

1 PA (for anterior teeth)

(Always use sensor positioning devices, ex: ring device; at least 2 straight/shifted - mesial or distal or vertical angulation)

For an endo diagnosis, how many and what type of radiographs should you take?

Cracks

What does this show on the tooth?

Perforation

What does this show on the tooth?

Sinus tract

What does this show on the tooth?

1. Pulp diagnosis

2. Periapical diagnosis

What are the 2 steps after clinical and radiographic examination to get to the correct diagnosis?

Pulp diagnosis

Pulp or apical diagnosis?

- Previously treated

- Previously initiated therapy

Apical diagnosis

Pulp or apical diagnosis?

- Condensing osteitis

normal pulp

ID the pulpal diagnosis:

- Pt has no symptoms

- Cold test: 1-2 seconds

- No intra-oral findings

normal pulp

AAE Terminology definition:

A clinical diagnostic category in which the pulp is symptom-free and normally responsive to pulp testing.

reversible pulpitis

ID the pulpal diagnosis:

- CC: "My tooth hurts when I drink cold or eat sweets"

- Cold test: Hypersensitive non lingering (2-3 sec)

- Radiograph shows defective restoration

reversible pulpitis

AAE Terminology definition:

- A clinical diagnosis based on subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal

(Pain not spontaneous it is triggered by stimuli A-delta fiber activation)

1. Caries

2. Exposed dentin

3. Defective restoration

4. Recent restoration

What are 4 causes of reversible pulpitis?

- Tx: Remove source of irritation

- Prognosis: follow up

What is the treatment and prognosis for reversible pulpitis?

The disease will progress to a certain point that the pulp tissue is incapable of healing

The pulp tissue is compromised in its ability to respond to external irritants because it's enclosed in a noncompliant environment, and it lacks collateral circulation. What will happen if the pulp is not treated?

asymptomatic irreversible pulpitis

ID the pulpal diagnosis:

- Patient reports no symptoms

- Cold test: Hypersensitive non lingering (2-3 sec)

- Radiograph shows very deep caries into the pulp chamber

asymptomatic irreversible pulpitis

AAE Terminology definition:

- A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing.

- Additional descriptors: no clinical symptoms but inflammation produced by caries, caries excavation, trauma

- Left untreated can become symptomatic or necrotic

1. RCT

2. Extraction

What is the treatment for asymptomatic irriversible pulpitis?

deep caries

What is the difference between reversible pulpitis + asymptomatic irriversible pulpitis?

symptomatic irreversible pulpitis

ID the pulpal diagnosis:

- CC: "My tooth hurts randomly, I can't even touch it"

- Cold test: Hypersensitive lingering (30 sec or more)

- Radiograph shows very deep caries into the pulp chamber

symptomatic irreversible pulpitis

AAE Terminology definition:

- A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing.

- Additional descriptors: lingering thermal pain, spontaneous pain, referred pain

symptomatic irreversible pulpitis

What is the diagnosis?

- Pain relievers don't work

- C-fibers activation (dull, throbbing pain)

- Pain is spontaneous/unprovoked

1. Deep restorations/caries reaching the pulp

2. Fractures/cracks

3. Crown prep close to pulp

4. Pulp exposure

4 causes of symptomatic irreversible pulpitis

1. RCT

2. Extraction

What is the TX for symptomatic irreversible pulpitis?

pulpal necrosis

ID the pulpal diagnosis:

- CC: "One of my teeth is darker than the others"

- Cold test: Negative (not responding)

- Radiograph shows tooth with intact pulp chamber (non-calcified)

- Rarification visible around apex

- Asymptomatic, blood supply nonexistent

- Pulpal nerves are nonfunctional

pulpal necrosis

AAE Terminology definition:

- A clinical diagnostic category indicating death of the dental pulp.

- The pulp is usually nonresponsive to pulp testing.

- RCT

- Extraction

What is the TX for pulpal necrosis?

previously treated pulp

ID the pulpal diagnosis:

- CC: "I have pain when biting on my tooth"

- Cold test: Negative

- Radiograph shows endo treatment of problematic tooth

previously treated pulp

AAE Terminology definition:

- A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials other than intracanal medicaments.

HPI

If patient had RCT ALWAYS ask when and where the root canal was done for what section in the medical history?

1. TAPER - adequate/thin/large

2. DENSITY- good/poor

3. WORKING LENGTH- at WL/short/ long (all obturation material/ sealer puff)

4. VOIDS- obturation/ between obturation and post/ between obturation and core buildup

5. PERIAPICAL AREA - intact lamina dura/ widening of PDL/ PARL

6. OTHERS- missed canal/ perforation/fiber post/ instrument separation

When evaluating a previously treated RCT, what are 6 things to consider?

previously initiated therapy

ID the pulpal diagnosis:

- CC: "I was having pain in my tooth, my dentist did something and the pain went away, so I'm not sure why she sent me to you, the endodontist"

- Cold test: inaccurate

- Radiograph shows partial temp filling in pulp chamber with cotton replacing the pulp

previously initiated therapy

AAE Terminology definition:

- A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (eg, pulpotomy, pulpectomy).

Apical

Pulp disease progresses in the ______ direction

reversible pulpitis

A patient presents with sharp pain to cold stimuli that quickly subsides upon removal of stimulus but lasted longer than control tooth, with no significant radiographic findings. What is the most likely pulpal diagnosis?

d) EPT only #20 for a proper diagnosis

A 20-year-old pt. came to the dental office to eval. #20. After cold testing, no teeth responded to cold, including control teeth, even after testing different surfaces of tooth. What is the next step?

A) Repeat cold test until pt. responds

B) Cross check information with EPT

c) No need to repeat cold test since both teeth are necrotic

d) EPT only #20 for a proper diagnosis

normal apical tissues

ID the apical diagnosis:

- Palpation: Non-tender/0

- Percussion: Non-tender/0

- Swelling: no

- Sinus Tract: no

- Pain: no

- Periapical Radiolucency: no

- The lamina dura surrounding the root is intact and the periodontal ligament space is uniform.