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Dr Nawaf Al-Hazaimeh

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* Diagnosis is the science of recognizing disease by means of signs,
symptoms, and tests. Often, diagnosis is straightforward; sometimes it is not. The basic steps in the diagnostic process are as follows:

* 1. Chief complaint * 2. History: medical and dental * 3. Oral examination * 4. Data analysis differential diagnosis * 5. Treatment plan

Diagnosis
key to start the Endo procedure

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*Medical History Review *Subjective History *Objective Testing *Analysis of data collected Clinical diagnosis *Plan of Action

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*Review/update written medical questionnaire *Medications *Allergies *Need for SBE prophylaxis *Diabetes *Pregnancy *Written consultation with physician as required

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Diabetes *Do not treat uncontrolled diabetics *Schedule appointment for early morning *Ensure that patient has had morning
insulin and breakfast

*Have a source of sugar readily available

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Latex Allergy

* Non-latex rubber dam * Latex-free gloves * One report of allergy to gutta-percha no definitive
proof that a true allergic reaction occurred

* Consult patients allergist

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The only systemic contraindications to endodontic therapy are:

* Uncontrolled diabetes * A very recent myocardial infarct

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Chief complaint

*In patients own words *My tooth hurts when I chew hard foods *I cant drink cold soda

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Pain History

*Location *Intensity *Duration *Stimulus *Relief *Spontaneity

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Very poorly localized

*Intermittent *Throbbing *Intensified by heat, cold and


sometimes chewing

*May be relieved by cold *Usually severe

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*May be well localized *Deep pain *Intensified by chewing *Moderate to severe in intensity

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* Gives rise to tentative diagnosis * Determines urgency of treatment * Confirmed by examination and special tests

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* Visual Examination * Radiographs * Percussion * Palpation * Mobility * Thermal tests

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* Electric Pulp Test * Periodontal probing * Selective anesthesia * Test cavity * Transillumination * Occlusion

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*Extra-oral examination
*Facial asymmetry *Swelling *Extra oral sinus tract *TMJ

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Intra-oral examination

*Soft tissue lesions


*Swelling *Redness *Sinus tract

Extra oral sinus tracts associated with necrotic teeth

A sinus tract should be traced with a gutta-percha cone

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Hard tissues

*Caries *Large or defective restorations *Discolored/chipped teeth

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* Always take your own pre-operative radiograph * Never make a diagnosis based on radiographic evidence
alone

Characteristic J-shaped or halo lesion associated with fractured root

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*A very significant test *Always compare suspect tooth with adjacent
and contralateral teeth *Tenderness indicates inflammation in the PDL *Cause of inflammation may be pulpal or periodontal

Vertical percussion

Horizontal percussion

Tooth Slooth Used to assess cracked teeth and incomplete cuspal fractures

* Extraoral
* To detect swollen or tender lymph nodes

* Intraoral
* May detect early periapical tenderness * Identifies soft tissue swelling * Must compare with other areas

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*Reflects the extent of inflammation in the PDL *Compare with adjacent and contralateral teeth *There are many causes of mobility besides pulpal
inflammation extending into the PDL

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*Cold always used *Heat rarely used *Compare reaction with adjacent and
contralateral teeth

*Refractory period of at least 10 minutes


before pulp can be retested accurately

CO2 Snow

Ice stick

*Isolate area with cotton rolls *Dry teeth to be tested *Ask patient to:
*Record:

*Raise hand on feeling cold *Lower hand when cold feeling goes away
*+ or sensitivity to cold *Time until cold sensitivity was felt *Time that cold sensitivity lingered

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Classic Responses to Thermal (cold) Testing: *Normal Pulp: Moderate transient pain *Reversible Pulpitis: Sharp pain; subsides quickly *Irreversible pulpitis: Pain lingers *Necrosis: No response
(Note false positive and false negative responses common)

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*A direct test of nerve elements of pulpal
tissue *Vitality versus non-vitality only not whether vital pulp is normal or inflamed *In multi-rooted teeth, where one canal is vital tooth usually tests vital *False positives and false negatives may occur

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False positive reading:

*Electrode contact with metal restoration or gingiva *Patient anxiety *Liquefaction necrosis *Failure to isolate and dry teeth prior to testing

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False negative reading

*Patient is heavily premedicated *Inadequate contact between electrode and enamel *Recently traumatized tooth *Recently erupted tooth with open apex *Partial necrosis

An isolated deep pocket may indicate a root fracture

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*May help to identify the
possible source of pain *An IDN block can localize pain to one arch *Ability to anesthetize a single tooth has been questioned

Helps to identify vertical crown fracture Produces light and dark shadows at fracture site. A crack will block and reflect the light when transilluminated

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*Analyze the data gathered via:
* History * Examination * Special tests

*Arrive at a clinical (not histologic) diagnosis:


* Pulpal diagnosis * Periapical diagnosis

*Normal *Reversible pulpitis *Irreversible pulpitis *Necrosis *Previous endodontic treatment

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*Symptoms *Radiograph *Pulp tests *Periapical tests
None
No periapical change Responds normally Not tender to percussion or palpation

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*Symptoms *Radiograph *Pulp tests *Periapical tests
May have thermal sensitivity
No periapical change Responds sensitivity not lingering Not tender to percussion or palpation

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*Symptoms *Radiograph *Pulp Tests *Periapical tests
May have spontaneous pain No periapical change Pain that lingers Generally not tender to percussion or palpation

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* Symptoms * Radiograph * Pulp tests * Periapical tests
No thermal sensitivity Dependent on periapical status

No response
Dependent on periapical status

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*Normal *Acute apical periodontitis *Chronic apical periodontitis *Chronic apical periodontitis with symptoms *Acute apical abscess *Chronic apical abscess *Condensing osteitis

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* Symptoms * Radiograph * Pulp tests * Periapical tests
None No periapical change Responds normally Not tender to percussion or palpation

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*Symptoms *Radiograph *Pulp tests *Periapical tests
Pain on pressure No periapical change +/- depending on pulp status

Tender to percussion and/or palpation

High restorations, traumatic occlusion, orthodontic treatment, cracked teeth, vertical root fractures, periodontal disease and maxillary sinusitis may also produce this response

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* Symptoms * Radiograph * Pulp tests * Periapical tests
None Periapical radiolucency No response Not tender to percussion or palpation

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*Symptoms *Radiograph *Pulp tests *Periapical tests

Pain on pressure Periapical radiolucency No response Tender to percussion and/or palpation

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*Symptoms *Radiograph *Pulp tests *Periapical tests
Swelling and severe pain +/- periapical radiolucency No response Tender to percussion and palpation

Acute apical abscess

Incision and drainage

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*Symptoms *Radiograph *Pulp tests *Periapical tests

Draining sinus usually no pain Periapical radiolucency No response Not tender to percussion or palpation

Extra oral sinus tracts associated with necrotic teeth

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* Treatment decisions are based on:
* Pulpal diagnosis * Periapical diagnosis * Restorability of tooth * Periodontal considerations * Difficulty of case * Financial considerations

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Two major decisions:
* Is root canal therapy indicated? * Should I carry out this treatment myself or should I
refer the case?

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*Patient considerations *Objective clinical findings *Additional conditions

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*Medical history *Local anesthetic considerations *Personal factors and general considerations

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* Diagnosis * Radiographic findings * Pulpal space * Root morphology * Apical morphology * Malpositioned teeth

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*Restorability *Existing restoration *Fractured tooth *Resorptions *Endo-perio lesions *Trauma *Previous endodontic treatment *Perforations

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* Pulpal necrosis * Chronic apical abscess * RCT and restoration * Medical history does not affect treatment plan

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Pulpal Diagnoses

*Normal *Reversible pulpitis *Irreversible pulpitis *Necrosis

Periapical Diagnoses

* Normal * Acute periradicular periodontitis * Chronic periradicular periodontitis * Acute apical abscess * Chronic apical abscess * Condensing osteitis

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To all intents and purposes a diagnosis of acute or chronic apical periodontits, acute or chronic apical abscess and condensing osteitis are associated with pulpal necrosis

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Treatment Planning

* Root canal therapy is indicated in situations in which the


pulp cannot recover:

* Irreversible pulpitis * Pulpal necrosis

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Following root canal therapy
* Posterior teeth must be restored with a crown. * A post may be required if there is insufficient tooth structure
to retain a core

* Anterior teeth may not require a full coverage restoration