Endodontic diagnosis

Diagnosis > is the art and science of detecting and distinguishing deviations from health and
the cause and nature of complaints

The purpose of a diagnosis :

1. Determine what problem the patient is having . Why the patient is having that problem
2 . Diagnosis The determination of the nature of a disease made from a study of the signs
and symptoms of a disease

There are two scenarios of diagnosis in Endodontic :

1.Emergency cases : such as pain , swelling , and traumatic tooth (particularly avulsion ).
2. Prosthetic and restorative purpose.

A strategy for summarizing the important points of

each clinical case

S.O.A.B
➤ Subjective -The chief complaint -The history of the present condition-The medical and
dental histories
➤ Objective-Extra oral Examination-Intraoral Clinical examination-Endodontic test -
Radiographic images
➤Assessment-Diagnosis -Etiology -prognosis
➤ Treatment plan -Endodontic- Periodontal - Restorative

Subjective
The chief complaint :The patients own words that describe the symptoms causing the
discomfort. The clinician should ask the patient what is your problem through open- ending
questions . he should avoid leading question , yes or no questions
The history of the present condition (dental history interview)
The Localization: " Can you point to the offending tooth ? " Commencement : " When did the
symptoms first occur ? "
Intensity : " How intense is the pain ? "
Provocation and Relief of Pain : " What produces or reduces the symptoms ? Mastication and
locally applied temperature changes account for the majority of initiating factors that cause
dental pain. On occasion, a patient may present to the dental office with a cold drink in hand
and state that the symptoms can only be reduced by bathing the tooth in cold water this
could be seen in late stage of irreversible pulpitis when C- fiber nerve is stimulated ( C- fiber
nerve located in the apical part of the root and stimulated by heat only and produce dull pain
, whereas A- delta fiber nerve located in the crown and stimulated by cold and heat and
produce sharp pain ) . Some symptoms may be relieved by nonprescription pain relievers,
and others may require narcotic medication for the reduction of symptoms.
Duration: “Do the symptoms subside shortly, or do they linger after they are provoked?”.it is
documented in terms of seconds or minutes.
The clinician should ask briefly about : Onset ( intermittent or spontaneous ) , Quality of pain
( dull , sharp , throbbing , and constant) . Lingering pain mostly start to subside after 5 -10
seconds . " Duration : " Do the symptoms subside shortly , or do they linger after they are
provoked “
DENTAL HISTORY : to GET 3 points :
• Which diagnostic tests are to be performed
• Recent dental manipulations.
• Any prior treatment rendered by other practitioners

MEDICAL HISTORY : TO GET 2 PIONT

1- medical conditions and current medications that will necessitate altering the manner
in which dental care will be provided and
2- medical conditions that may have oral manifestations or mimic dental pathosis

Objective
Extra oral examination :
facial asymmetry ➤ Visual and palpation examinations
palpation when a unilateral “lump or bump” is present
-Extraoral facial swelling of odontogenic origin
typically is the result of endodontic etiology because diffuse facial swelling resulting from a
periodontal abscess is rare ,A subtle visual change such as loss of definition of the nasolabial
fold on one side of the nose may be the earliest sign of a canine space infection . Extremely
long maxillary central incisors may also be associated with a canine space infection, but most
extra oral swellings associated with the maxillary centrals express themselves as a swelling of
the upper lip and base of the nose . If the buccal space becomes involved, the swelling will
be extra oral in the area of the posterior cheek . These swellings are generally associated
with infections originating from the buccal root apices of the maxillary premolar and molar
teeth and the mandibular premolar and first molar teeth. The mandibular second and third
molars may also be involved, but infections associated with these two teeth have as much
likelihood to exit to the lingual where other spaces would be involved. Extra oral swelling
associated with mandibular incisors will generally exhibit itself in the submental or
submandibular space. Infections associated with any mandibular teeth, which exit the
alveolar bone on the lingual and are inferior to the mylohyoid muscle attachment, will be
noted as swelling in the submandibular space. palpation of swelling to determine it is
localized or diffused , firm or fluctuant .

Palpation of lymph node ➤ firm and tender along with facial swelling and an elevated
temperature Sinus tract ➤ in the skin of the face - A scar is more likely to be visible on the
skin surface in the area of the sinus tract stoma than on the oral mucosal tissue
Intra oral examination : check the Color or texture - Lesions or ulcerations
Intra oral swelling ➤ Present in the attached gingiva , alveolar mucosa , mucobuccal fold ,
palate , or sublingual tissues .
• Determine whether the etiology is endodontic , periodontic , or a combination of these
two or whether it is of nonodontogenic origin facial swelling

Intra oral Sinus tracts :

Sinus tract ➤chronic intraoral communication between the gingival surface and source of
the infection sometimes lined with epithelium or granulation tissue
-The stoma of the sinus tract may be located directly adjacent to or at a distant site from the
infection
- May open in the alveolar mucosa , in the attached gingiva , through the furcation or gingival
crevice
tracing doing by 25 or #30 gutta-percha cone is threaded into the opening of the sinus tract

Clinical endodontic test:

periodontal disease: Endodontic etiology of Periodontal disease ➤Isolated areas of vertical
bone loss , specifically from a nonvital tooth whose infection has extended from the periapex
to the gingival sulcus

Palpation :Detecting any soft tissue swelling or boney expansion .

• The clinician should ask the patient about any areas that feel unusually sensitive
during this palpation part of the examination
Percussion :-Periapical test , not a test of pulp vitality Tenderness to percussion indicates
1. The presence of periradicular inflammation
2. May determine the degree of inflammation in the periodontal ligament

MOBILITY
• Provides an indication of the integrity of the attachment apparatus .
Causes of tooth mobility :
-The purulent exudate of an acute periradicular abscess
- Root fracture -Recent trauma
- Chronic bruxism
- Orthodontic tooth movement

Because determining mobility by simple finger pressure can be visually subjective, the back
ends of two mirror handles should be used, one on the buccal aspect of the tooth, and one
on the lingual aspect of the tooth . Classification :
Grade I :sign of movement greater than normal.
Grade II : Horizontal tooth movement no greater than 1 mm .
Grade III : Horizontal tooth movement greater than 1 mm , with or without visualization of
rotation or vertical deperssability
• Movement of more than 2 to 3 mm or depression due to : Primarily periodontal : Poor
prognosis for root canal treatment
Endodontic origin : Decreased by endo treatment .
Clinical endodontic test:

Sensitivity test
Pulp testing Determination of the responsiveness of pulpal sensory neurons
Thermal Test ( Cold , Heat ) - Electrical Pulp Test ( EPT )
Normal response: Sensation is felt but disappears immediately on removal of the thermal
stimulus
Abnormal response :
1 . Lack of response to the stimulus .
2. Lingering painful sensation after the stimulus is removed .
3 . Severe pain sensation as soon as the stimulus is placed on the

Cold test ➤ It is the Primary pulp testing method for many clincians today
Cold Tests Ice stick ( 32 ° F / 0 ° C ) 1,1,1,2tetrafluoroethane ( Endo Ice ) ( -26.2C )
Dry Ice ( CO2 Snow ) ( -108 ° F / -78 ° C )
Ethyl chloride ( -4 ° F / -41 ° C ) . Cold water bath ( 32 ° < F / 0 ° < C )
Hot Tests ➤ useful when a patient's chief complaint is intense dental pain on contact with
any hot liquid or food .
It is appropriate when a patient is unable to identify which tooth is sensitive . Heated gutta
percha ( 150 C ) -Frictional heat using rubber cup -The System B ( 150 F )

Clinical endodontic test:

Electrical Pulp Tests ( EPT ) Determine the presence or
absence of sensory nerves and supposedly of a vital pulp
Factors affect the level of response :
1. Enamel thickness .
2. Probe placement on the tooth .
3. Dentin calcification
4. Interfering restorative materials .
5. Cross sectional area of the probe tip .
6. Patient's level of anxiety .
7. Age of erupted tooth .

Clinical endodontic test:

Cold test was 86 % accurate .
Heat test was 71 % accurate
EPT was 81 % accurate .
Cold tests have been shown to be more reliable than EPT in younger patients with less
developed root apices
why the EPT might give false -Ve ?
1. Newly erupted teeth >>>> delayed development of the nerve
2. Recently traumatized >>>>> Nerve coma

Vitality test
Clinical endodontic test:
•Control teeth ➤ have three functions
1-The patient learns what to expect from the stimulus .
2-The dentist can observe the nature of the patient's response to a certain level of stimulus
and determine the stimulus is capable of invoking a response .
3-The device can evokes stimulus : integrity of the device
. Contralateral and adjacent teeth ( before and after offending one )
•Cavity Test ➤ Using low speed or spoon excavator
If the tooth fails to respond to cold , but it does respond to EPT • Cavity preparation
without anesthesia >>> dentin stimulation
1. Vital >>> sensitivity to pain when reach dentin >> restoration only

Clinical endodontic test:

Selective Anesthetic Test ➤ When the patient cannot determine which arch the pain is
coming from .
• First selectively anesthetize the maxillary arch .
• Accomplished by using ( intraligamentary ) injection .
• Injection is administered to the most posterior tooth in the quadrant of the arch that
may be suspected , starting from the distal sulcus .

Bite Test ➤ This test is confirmatory if the patient reports pain upon mastication
. A common finding with a fractured cusp or cracked tooth is the frequent presence of
pain on release of biting pressure

Radiographic Examination Diagnosis should based on :

1. The continuity and shape of the lamina dura
2. The width and shape of the periodontal ligament space .
3. Bony architecture .
4. The root canal system is within normal limits . No evidence of resorption or calcification .

Limitation of Radiographs >The radiograph gets a two - dimensional image of three -

dimensional reality

Buccal objective rule ( BOR ) / Clark's rule / SLOB Clark 1909

Distinguish between normal anatomical landmarks and the radiolucent shadows associated
with pathosis of the roots of teeth . Locate foreign bodies in trauma cases , Locate hidden
apices prior to periapical surgery Determine the buccal or lingual position of root fractures ,
perforations

AAE Consensus Conference Recommended Diagnostic Terminology

Normal pulp A clinical diagnostic category in which the pulp is symptom-free and normally
responsive to pulp testing.
Reversible pulpitis A clinical diagnosis based on subjective and objective findings indicating
that the inflammation should resolve and the pulp return to normal.
Symptomatic irreversible pulpitis A clinical diagnosis based on subjective and objective
findings indicating that the vital inflamed pulp is incapable of healing. Additional descriptors:
lingering thermal pain particularly to cold , spontaneous pain, referred pain.
Asymptomatic irreversible pulpitis 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.
Pulp necrosis A clinical diagnostic category indicating death of the dental pulp. The pulp is
usually nonresponsive to pulp testing.
Previously treated A clinical diagnostic category indicating that the tooth has been
endodontically treated and the canals are obturate with various filling materials other than
intracanal medicaments.
Previously initiated therapy A clinical diagnostic category indicating that the tooth has been
previously treated by partial endodontic therapy (eg, pulpotomy, pulpectomy).
Apical
Normal apical tissues Teeth with normal periradicular tissues that are not sensitive to
percussion or palpation testing. The lamina dura surrounding the root is intact, and the
periodontal ligament space is uniform.
Symptomatic apical periodontitis Inflammation, usually of the apical periodontium,
producing clinical symptoms including a painful response to biting and/or percussion or
palpation. It might or might not be associated with an apical radiolucent area.
Asymptomatic apical periodontitis Inflammation and destruction of apical periodontium that
is of pulpal origin, appears as an apical radiolucent area, and does not produce clinical
symptoms.

Acute apical abscess An inflammatory reaction to pulpal infection and necrosis characterized
by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation, and
swelling of associated tissues.
Chronic apical abscess An inflammatory reaction to pulpal infection and necrosis
characterized by gradual onset, little or no discomfort, and the intermittent discharge of pus
through an associated sinus tract.
Condensing osteitis Diffuse radiopaque lesion representing a localized bony reaction to a
low-grade inflammatory stimulus, usually seen at apex of tooth.
Cellulitis This is another form of abscess characterized by a symptomatic edematous
inflammatory process. Invasive microorganisms spread diffusely through the connective
tissue and facial planes, to create various degrees of swelling and discomfort.
Apical Scar The apical scar is a dense collagenous connective tissue "scar" in the bone with a
distinctive presentation. It is a dark radiolucency found at or near the apex of a tooth that
has been surgically treated. It is a form of repair but is commonly associated with lesions that
have been involved with the destruction of both the facial and lingual osseous cortical plates.
Comments:
1- Another form of irreversible pulpitis is hyperplasic pulpitis. Also referred to as a pulp
polyp. this is a growth of pulp tissue from the pulp chamber that is usually covered with
epithelium which result from caries or trauma . This is typically seen again in a younger
population and can be found in both primary and permanent dentition.
2- internal resorption consider as asymptomatic irreversible pulpitis .
3- The term abscess is used when signs of swelling or exudate are present or believed to be
occurring.