Overview
Endodontic examinations and diagnoses need to be accurate. There are multiple guides but I find the American Association of Endodontists most helpful and thorough. Firstly, it begins with a medical and dental history. Secondly, this is followed by chief complaint. Thirdly, there are clinical exams to assess facial symmetry, sinus tracts, periodontal status, caries and defective restorations. Fourthly, there are tests to run to test for pulpal (cold, electric and plural tests) and periodical statuses (percussion, palpation and tooth slooth). Fifthly, there are some radiographic analysis. Sixthly, if need be, there are additional tests such as transillumination, selective anaesthesia and test cavity.
Step 1: Medical & Dental History
To get an idea of how to treat the patient, it is important to ask about the previous dental experience, their past/ recent treatments, and drugs.
Step 2: Chief Complaint
This includes a series of questions related to the patient's condition best remembered by the acronym COLD SPA.
Character: how would you describe your pain?
Onset: when did your pain start?
Location: where is the pain?
Duration: how long does the pain last?
Severity: how would you rate your pain on a scale from 1 - 10?
Pattern: what triggers your pain?
Associations: do you have any other symptoms?
Step 3: Clinical examination
Facial symmetry
Sinus tract
Periodontal status
Periodontal probing depths: uses 6 point charging of the tooth to measure from the gingival margin to the junctional epithelium. Anything less than 3mm recorded as WNL (within normal limits) or NAD (no abnormalities)
gingival recession: measured from the cemento-enamel junction to the gingival margin
total attachment loss = gingival recession + periodontal pocket depth
mobility: Grade 0, I (1mm), II (1-2mm), III (>2mm, up & down movements). The movement of tooth in its socket resulting from an applied force, usually measured on an increasing scale of 1 – 3 or measured by the amount of horizontal and/ or vertical mobility in milli- meters
Step 4: Conduct pulp sensibility tests
Once the interview is complete, dentists need to run a series of tests. These tests provide clues for making a pulpal and also a peri-apical diagnosis.
Pulp sensibility tests
Cold test is the most sensitive test and the most commonly ran test. It involves using a frozen stick of carbon dioxide or a cotton pellet sprayed with 1,1,1, 2 tetrafluoroethane at -78 degrees Celsius, on the buccal surface of the tooth. This is applied also to the tooth next door and with the tooth on the opposite side. Use scale 0/10 for intensity and record duration of the response 1s – 30 s for lingering.
Heat test uses a heated gutta percha. After a heat or cold test, you may have the following results:
No pain (-) or delayed (+)(D)usually suggestive of necrosis
Sensation (-) usually suggestive of normal tissue
Lingering pain ++ (L) usually suggestive of irreversible pulpitis
Non-lingering pain (++) usually suggestive of irreversible pulpitis
Electric pulp test stimulates the A-delta fibres but do not have enough current to stimulate C fibres. After an electric pulp test, you may have the following results.
No pain (-) usually suggestive of necrosis, or normal tissue
Pain (+) usually suggestive of reversible pulpitis or irreversible pulpitis
Peri-apical Tests
There are several tests which could be run to form a peri-apical diagnosis.
Percussion involves tapping the cusp of the tooth a few times with the back of a mirror. If the patient senses pain or tenderness, this is recorded as a positive.
Palpation: using touch to determine texture, rigidity, and tenderness
Frac-finder: test cusp by cusp
Step 5: Radiographic Analyses
Peri-apical radiographs (at least 2)
Bitewings
Cone - beam computed tomography
Step 6: Additional Tests
A less common method is a test cavity in which a small cavity is prepared without anaesthesia into the dentine to test for pulpal responsiveness.
Step 7: Reach Endodontic Diagnosis
Taking into account chief complaints, symptoms and clinical findings, it is possible to arrive at a pulpal diagnosis.
Normal: sensitive to hot and cold but no pain
Reversible pulpitis: Some discomfort, inflammation but it returns to normal. No visible radiographic changes noted. This can be caused by exposed dentine, caries or deep restorations. They may have short, sharp, shooting pain upon a thermal stimulus.
Symptomatic irreversible pulpitis: Vital inflamed pulp is incapable of healing, so root canal treatment will be needed. There is sharp pain upon application of the stimulus and it lasts 30 seconds longer after the stimulus is removed. It may not have reached peri-apical tissues, so it may not be sensitive to percussion.
Asymptomatic irreversible pulpits: Vital inflamed pulp is incapable of healing. They would respond normally with no pain to thermal testing.
Previous treated: the canals have been previously treated or filled with materials other than medicaments. The tooth does not respond to thermal or pulpal testing.
Previously initiated: tooth has been treated by partial or full pulpectomy. Depending on the level of the pulpectomy, the tooth may or may not respond to pulp testing.
Necrosis: death of the dental pulp, which indicates the need for root canal treatment. Pulp is not responsive to pulp testing and is asymptomatic. Some teeth may not be responsive due to calcification, recent history of trauma or simply the tooth not responding.
After running the tests and comparing the results to the radiograph, the dentist is able to form one of the following diagnosis.
Normal: Normal tissues are not sensitive to percussion or palpation. Radiographically the lamina dura and the periodontal ligament space is uniform. As with pulp testing, comparative testing for percussion and palpation should always begin with normal teeth as a baseline for the patient.
Symptomatic apical periodontitis: There is pain to percussion, palpation or biting. This may be accompanied by radiographic changes. The periodontal ligament may look normal or there may be a peri-apical radiolucency.
Asymptomatic apical periodontitis: inflamed and destroyed apical periodontium that is of pulpal origin. It appears as an apical radiolucency and does not present any symptoms.
Acute apical abscess: characterised by rapid onset, spontaneous pain, extreme tenderness of the tooth to pressure, pus formation and swelling of associated tissues. There may be no radiographic signs of destruction and the patient experiences malaise, fever and lymphadenopathy.
Chronic apical abscess (draining sinus): There is little or no discomfort and an intermittent discharge of pus through the an associated sinus tract. Radiographically, there are typically signs of osseous destruction such as radiolucency. To identify the source of a draining sinus tract when present, a gutta percha cone is carefully placed through the stoma or opening until it stops and a radiograph is taken.
Condensing osteitis: a diffuse radiopaque lesion representing a localised bony reaction to a low - grade inflammatory stimulus usually seen at the apex of the tooth.
Step 8: Assess Difficulty
In a solid treatment plan, the dentist assesses the difficulty and then informs the patient about the risk of failure. You can find more information about what constitutes a difficult tooth here. Among the inclusions for a difficult tooth include a very angulated root canal system, a second or a third molar, and a tooth which is longer than 25mm. If the treatment has high difficulty, it is necessary to refer the patient to an endodontics specialist.
Comentários