CLINICAL DIAGNOSIS OF ENDODONTIC PATHOSIS

Editor's Notes

• #7: Explain chief complaint, hopi A sample form used in diagnosis and treatment planning
• #9: Examples of the type of questions which may be asked are given below: EXPLAIN In cases of pulpitis, the decision the operator must make is whether the pulpal inflammation is reversible, in which case it may be treated conservatively, or irreversible, in which case either the pulp or the tooth must be removed, depending upon the patient’s wishes. If symptoms arise spontaneously, without stimulus, or continue for more than a few seconds after a stimulus is withdrawn, the pulp may be deemed to be irreversibly damaged. Applications of sedative dressings may relieve the pain, but the pulp will continue to die until root canal treatment becomes necessary. This may then prove more difficult if either the root canals have become infected or if sclerosis of the root canal system has occurred. The correct diagnosis, once made, must be adhered to with the appropriate treatment. In early pulpitis the patient often cannot localise the pain to a particular tooth or jaw because the pulp does not contain any proprioceptive nerve endings. As the disease advances and the periapical region becomes involved, the tooth will become tender and the proprioceptive nerve endings in the periodontal ligament are stimulated
• #10: History of present illness+ Intra oral examination-cisual and tactile + Radiographic + Other Tests:  Subjective Symptoms are those which are experienced and reported to the clinician by the patient. 2. Objective Symptoms are those, which are obtained by the clinician through various tests
• #11:  Grossman has stated Pulpal pain to be of the following two varieties :   Accordong to Grossman: Ø Sharp, piercing and lancinating -- a painful response usually associated with the excitation of the A-DELTA nerve fibers. This pain usually reflects REVERSIBLE state. Ø Dull, borinq, gnawing and excruciating-- a painful response usually associated with the excitation of C-nerve fibers.- Ø Usually reflects an irreversible state of pulpitis.
• #12:  Grossman has stated Pulpal pain to be of the following two varieties : - Excellent chance of recovery without the need for endodontic treatment-rev case
• #13: Patients may report that their dental pain is exacerbated while lying down or bending over  This occurs because of the increase in blood pressure to the head, which therefore increases the pressure on the confined pulp
• #14: Thus pain, which is recorded as the complaint is considered to conclude an acute or chronic, reversible or irreversible condition of the pulp.
• #15: Rev pulpitis: Characterized by pain which is of a :-  Shorter duration  Localized  May be piercing/ lancinating in nature  More responsive to cold than heat  Caused by a specific irritant & disappears as soon as it is removed 19.  Irrev:  Abnormal dental pain, which responds to heat  Which occurs on changing the position of the head, awakening the patient from sleep  Dull pain of Longer duration, which occurs during mastication in a Cariously exposed tooth
• #16: The clinician should look for:  Facial asymmetry  Localized swellings  Lymphadenopathy  Changes in color, bruises/ scars, similar signs of disease, trauma or of any various treatment.  Begins with a general evaluation of the oral structures. The occlusion is checked (for any derangements if any) The lips, cheeks, vestibules and mucosa are examined for any evident abnormalities.
• #18: Simplest and the easiest of the diagnostic tests Acc. To Grossman the prime objective of visual & tactile inspector is evaluation of the “3 C’s” viz: of hard and soft tissues Soft tissue: Color- the normal color of gingiva is coral pink. Change from this is easily visualized in inflammatory conditions. Contour- change in normal contour (eg, of scalloped gingiva) occurs with a swelling. Consistency- On inspection (most commonly gingiva) appears healthy, firm, resilient, while a soft, fluctuant or spongy tissue is more indicative of a pathological state. Color- Normal teeth show life like translucency & sparkle that is missing in pulpless teeth which appear more or less opaque. Note: This discoloration however could be due to a variety of other reasons like old amalgam restorations, tetracycline stains etc. Contour- This examination should also include the visualization of contours of affected teeth, such as fractured teeth, wear facets, improperly contoured restorations, or altered crown contours as these factors can have a marked effect on the respective pulps.  Consistency- Change in the consistency of hard dental tissues is related to the presence of caries, external and internal resorption
• #19: Employs the usage of the (index finger) fingertip, supplemented with a light digital pressure to examine tissue consistency and pain response. The importance of this test other than as an aid in locating the swelling over an involved tooth, is in determining the following:  Whether the tissue is fluctuant and enlarged sufficiently for incision and drainage.  The presence, intensity and location of pain.  The presence and location of Adenopathy  The presence of bony Crepitus. Digital pressure is used to check for tenderness in the oral tissues overlying the suspected teeth.Bimanual palpation is most efficient to detect incipient swellings before it is clinically evident
• #20:  Before percussing the involved tooth, instructions are to be given to the patient to raise his/ her hand or make an audible sound in order to let the clinician know when and whether the tooth feels “TENDER”, “DIFFERENT” or painful on percussion. Before percussing the teeth with the handle of the instrument (a mouth mirror etc), the quadrant of the involved tooth is percussed using the index finger with quick blows of low intensity. The teeth should be tapped (with the index finger) in a random fashion so that the patient cannot “anticipate” when the tooth will be percussed When no response is elicited on digital percussion, then the handle of an instrument is to be used/employed. 27. Percussion is done in both vertical and horizontal directions. Change the sequence of percussion in successive tests to eliminate bias. The force of percussion should only be strong enough for the patient to differentiate between a sound tooth and a tooth with inflamed periodontal ligament. The proprioceptive fibers in an inflamed periodontal ligament will, when percussed, help the patient and the clinician locate the source of pain. 28.  ormal resonant sound on percussion indicates good periodontal ligamentDull sound on percussion indicates ankylosis.Response to percussion not only indicates the involvement of the PDL but also the extent of the inflammation.(degree of response directly proportional to degree of inflammation). Chronic periapical inflammation is often negative to Percussion.
• #21: Horizontal bone loss with generalized pocket is not as worrisome as
• #22: Assessment of vitality using routine methods rely on the stimulation of Aδ nerve fibers and there is no direct indication of the blood flow. Three methods are used to stimulate the Aδ nerve fibers1. Thermal stimulation2. Electrical stimulation3. Direct dentin stimulation.
• #24: 3 METHODS OF STIMULATION: READ FROM SLIDESHARE DIAGNOSSI CONCEPT Heat causes vasodilatation and increase in intrapulpal pressure (releases gaseous product ofproteolysis) (VAN HASSEL).In an intact pulp specific pulpal temperaturemust be reached before there is pain from heat. Therefore, application of heat to normal teethgives delayed response.In a tooth with inflamed pulp, increased intrapulpal pressure already exists. Thereforeimmediate painful response to gradual/suddenincrease in heat. 51. COLDCold decreases intrapulpal pressure in normal intact pulp and there is no pain.The pain from cold is due to hydrodynamic mechanism.Contraction of fluid causes outward flow of fluid in dentinal tubules, deforms Aδ nerve and an action potential is generated.In advanced acute pulpitis, no Aδ receptors are present. Cold produces contraction and lowers the intrapulpal pressure to a sub threshold level and relieves pain due to still viable C fibers.Pain returns within 30 – 60 seconds as intra pulpal pressure returns to its former suprathreshold level. 52. ELECTRIC PULP TEST Electrolyte applied on the teeth to transmit current Jelly used for ECG is ideal When electrolyte contacts the tooth an electric charge is applied by pressing rheostat button. A small charge is released initially and increased until response is felt. Select control teeth – contra lateral teeth and adjacent teeth. www.indiandentalacademy.com 53. INTERPRETATION If the current required to gain a response from a test tooth is same as that needed to excite the control – the pulp of the test tooth is considered normal. If less current is required for a response – Hyperactive If more current is required– delayed response/ high pain threshold Lack of response – Pulpal necrosis www.indiandentalacademy.com 54.  Two readings are recorded and the average value is taken. “Using EPT on any tooth more than 4 times can give wrong reading due to additive action.” www.indiandentalacademy.com 55.  Only Aδ fibers are activated by electric tests Aδ fibers produce initial momentary sharp response to electric stimuli because of its peripheral location, low threshold & greater conduction velocity. Continuous constant pain is produced by the smaller C fiber stimulation as it is associated with tissue damage and inflammatory process
• #27: Calcificatin isolated or continuous
• #30: The pulpal nerve fibers, A-delta (which respond to cold and the EPT) and C-fibers (which respond to heat and elicit the nerve response when a patient reports spontaneous tooth pain), are nociceptors. Nociceptors are sensory receptors that respond to stimuli by sending nerve signals to the brain. This stimulus can cause the perception of pain in an individual.9 By objectively testing the pulpal nerve fibers, a dentist can best determine pulpal status. Diagnostic terminology approved by the American Association of Endodontists and the American Board of Endodontics5-7 Pulpal diagnoses9-\ One cannot arrive at a probable diagnosis without comparing the tooth in question with adjacent and contralateral teeth. It is best to test the adjacent teeth and contralateral teeth first so that the patient is familiar with the experience of a normal response to cold. Rev PulpitisL Discomfort is experienced when a stimulus such as cold or sweet is applied and goes away within a couple of seconds following the removal of the stimulus. Typical aetiologies may include exposed dentin (dentinal sensitivity), caries or deep restorations. There are no significant radiographic changes in the periapical region of the suspect tooth and the pain experienced is not spontaneous. Following the management of the aetiology (e.g. caries removal plus restoration; covering the exposed dentin), the tooth requires further evaluation to determine whether the “reversible pulpitis” has returned to a normal status. Although dentinal sensitivity per se is not an inflammatory process, all of the symptoms of this entity mimic those of a reversible pulpitis. Sym Irrev Pulpitis: . Sometimes the pain may be accentuated by postural changes such as lying down or bending over and over-the-counter analgesics are typically ineffective. Common aetiologies may include deep caries, extensive restorations, or fractures exposing the pulpal tissues. Teeth with symptomatic irreversible pulpitis may be difficult to diagnose because the inflammation has not yet reached the periapical tissues, thus resulting in no pain or discomfort to percussion. In such cases, dental history and thermal testing are the primary tools for assessing pulpal status.   Could result in irreversible pulpitis if cause not removed
• #31: The pulpal nerve fibers, A-delta (which respond to cold and the EPT) and C-fibers (which respond to heat and elicit the nerve response when a patient reports spontaneous tooth pain), are nociceptors. Nociceptors are sensory receptors that respond to stimuli by sending nerve signals to the brain. This stimulus can cause the perception of pain in an individual.9 By objectively testing the pulpal nerve fibers, a dentist can best determine pulpal status. Diagnostic terminology approved by the American Association of Endodontists and the American Board of Endodontics5-7 Pulpal diagnoses9-\ One cannot arrive at a probable diagnosis without comparing the tooth in question with adjacent and contralateral teeth. It is best to test the adjacent teeth and contralateral teeth first so that the patient is familiar with the experience of a normal response to cold. Rev PulpitisL Discomfort is experienced when a stimulus such as cold or sweet is applied and goes away within a couple of seconds following the removal of the stimulus. Typical aetiologies may include exposed dentin (dentinal sensitivity), caries or deep restorations. There are no significant radiographic changes in the periapical region of the suspect tooth and the pain experienced is not spontaneous. Following the management of the aetiology (e.g. caries removal plus restoration; covering the exposed dentin), the tooth requires further evaluation to determine whether the “reversible pulpitis” has returned to a normal status. Although dentinal sensitivity per se is not an inflammatory process, all of the symptoms of this entity mimic those of a reversible pulpitis. Sym Irrev Pulpitis: . Sometimes the pain may be accentuated by postural changes such as lying down or bending over and over-the-counter analgesics are typically ineffective. Common aetiologies may include deep caries, extensive restorations, or fractures exposing the pulpal tissues. Teeth with symptomatic irreversible pulpitis may be difficult to diagnose because the inflammation has not yet reached the periapical tissues, thus resulting in no pain or discomfort to percussion. In such cases, dental history and thermal testing are the primary tools for assessing pulpal status.  
• #37: For endodontic diagnostic purposes, the depth of caries past or present is an important radiographic indicator of teeth with pulpal pathosis. While carious exposures of the pulp cannot be seen radiographically, gross caries that approximates the radiographic outline of the pulp chamber is frequently evident even in the absence of symptoms (Fig. 3-5, A). Pulp exposure would be a logical expectation following excavation of such lesions, and root canal treatment of this tooth would be a necessary part of the treatment plan. . Fig. 3-6, A represents a symptomatic tooth with a carious lesion in close proximity to the mesial pulp horn. Excavation revealed a gross carious exposure and necrotic pulp. Root canal treatment was indicated
• #38: For endodontic diagnostic purposes, the depth of caries past or present is an important radiographic indicator of teeth with pulpal pathosis. While carious exposures of the pulp cannot be seen radiographically, gross caries that approximates the radiographic outline of the pulp chamber is frequently evident even in the absence of symptoms (Fig. 3-5, A). Pulp exposure would be a logical expectation following excavation of such lesions, and root canal treatment of this tooth would be a necessary part of the treatment plan. . Fig. 3-6, A represents a symptomatic tooth with a carious lesion in close proximity to the mesial pulp horn. Excavation revealed a gross carious exposure and necrotic pulp. Root canal treatment was indicated
• #39: For endodontic diagnostic purposes, the depth of caries past or present is an important radiographic indicator of teeth with pulpal pathosis. While carious exposures of the pulp cannot be seen radiographically, gross caries that approximates the radiographic outline of the pulp chamber is frequently evident even in the absence of symptoms (Fig. 3-5, A). Pulp exposure would be a logical expectation following excavation of such lesions, and root canal treatment of this tooth would be a necessary part of the treatment plan. . Fig. 3-6, A represents a symptomatic tooth with a carious lesion in close proximity to the mesial pulp horn. Excavation revealed a gross carious exposure and necrotic pulp. Root canal treatment was indicated
• #42: Radiographic Changes Associated With Pulpal Necrosis in Periapical Tissues The only pulpal conditions that cause periapical pathosis are (see Chapter 1). At the time of onset of apical inflammation, there may be no changes on a radiograph, yet the tooth will often be acutely tender to percussion, with radiographic changes usually following within a few days. The radiographic lesion which appears is the result of bone resorption caused by the necrotic pulpal tissue and bacteria emanating from the apical foramen. Many lesions develop slowly over a relatively long period of time. Even in cases of acute apical infection without a preexisting lesion, a radiographic lesion may not become evident for as long as 10 days.3,4 The earliest change will be observed as a widening of the periodontal ligament space in the region of the apical foramen. This can sometimes be subtle and difficult to distinguish from the variation seen in the normal apical anatomy. For this reason, the radiograph alone is insufficient to make a final diagnosis. A history of symptoms would be very important, and sensibility testing and the other forms of clinical evaluation would have to be done.
• #45: (or a “pulp polyp”) Nevertheless, because the inflammation is irreversible, tooth extraction or endodontic therapy is required.
• #47: . Diagnosis: Pulp necrosis; symptomatic apical periodontitis with condensing osteitis
• #48: Diagnosis: Symptomatic irreversible pulpitis; normal apical tissues. Non-surgical endodontic treatment is indicated; access is to be repaired with a permanent restoration. Note that the maxillary second premolar has severe distal caries; following evaluation, the tooth was diagnosed with symptomatic irreversible pulpitis (hypersensitive to cold, lingering eight seconds); symptomatic apical periodontitis (pain to percussion).
• #49: Diagnosis: reversible pulpitis; normal apical tissues. Treatment would be excavation of the caries followed by placement of a permanent restoration. If the pulp is exposed, treatment would be non-surgical endodontic treatment followed by a permanent restoration such as a crownin the region.
• #50: Diagnosis: pulp necrosis; asymptomatic apical periodontitis. Treatment is non-surgical endodontic treatment followed by bleaching and permanent restoration
• #51: Diagnosis: pulp necrosis; chronic apical abscess. Treatment is crown removal, non-surgical endodontic treatment and placement of a new crown.
• #52: . Diagnosis: previously treated; symptomatic apical periodontitis. Treatment is non-surgical endodontic retreatment followed by permanent restoration of the access cavity. Fig. 4 Fig. 5 | CE article diagnosis 14 roots 1 2016
• #53: . Diagnosis: pulp necrosis; asymptomatic apical periodontitis. Treatment is nonsurgical endodontic treatment and placement of a permanent restoration.  
• #54: With proper integration of clinical and radiographic factors,, the wise and prudent clinician should be able to assess both the process and completed treatment.