#D3/S2/W1
#Endo
Diagnostic process

• data gathering
  • history
  • clinical exam
  • radiographic exam
• diagnosis
• treatment options
• treatment plan and informed consent

Diagnosis

• rule out other causes of pain
  • TMD
  • occlusal interferences
  • non-odontogenic pain
• must perform pulp vitality tests
• if in doubt - do nothing irreversible

History

• presenting complaint
• history presenting complaint
• medical and dental history
• 

Clinical Examination

eo

• swelling
• masticatory muscles
• TMJ
• lymph nodes
  IO
• soft tissue (inflammation, swelling, sinus tract)
• occlusion (traumatic occlusion, fremitus)
• teeth: caries, cracks, restoration, discolouration (calcific metamorphosis, attrition erosion abrasion, developmental abnormalities (dens evaginatus)
• 
• tests
  • percussion, palpation, probing, mobility
• probing
  • discrete isolated pocket: VRF/crack or drainage via PDL (sinus tract)
  • broad pocketing (periodontal disease)
  • furcation involvement

Pulp testing

• EPT
• endofrost
• CO2 ice tests
• 2 purposes
  • identify problem tooth by reproducing chief complaint
  • determine a vital versus non vital pulp
• to test pulp vitality CO2 is considered most reliable
  • false negative response
    • dentinal scelroris (elderly)
    • young patient
    • trauma (inc ortho)
  • EPT typically used to confirm a negative response to CO2

Tracing sinus tract

• sinus tract doesnt always arise beside tooth that is contributing to pathosis
• 

Transillumination, staining (methylene blue), selective cuspal loading

• all undertaken for identification of cracked tooth particularly frac finder for recreating presenting complain (sharp transient pain on biting)

Selective anaesthesia

• unsure if pain is originating from what tooth
• elect to selectively anaesthetise and assess if pain has subsided or not

Radiographic examination

• must have good quality pre-op film
• periapical film + bitewing for all posterior teeth
• 
• CBCT imaging eliminates superimposition, useful as an aid in diffcult diagnosis
• 

misdiagnosis case

• referred to rct 31 and 42, retreat 41 for pain and swelling
• no tests performed, no diagnosis
• 31 and 42 CO2 positive
• advised no treatment for teeth 31 and 42
• option for revision vs surgery on tooth 41
• 
• positive CO2 always overrides radiographic appearance
• dont assume which teeth are involved based on size of radiolucency

Endodontic diagnosis

Pulpal diagnosis

• normal pulp
  • symptom free, normally response to pulp testing
• reversible pulpitis
  • vital inflamed pulp that may heal with vital pulp therapy
  • e.g. slight hypersensitivity to cold
• symptomatic irreversible pulpitis
  • vital inflamed pulp incapable of healing
  • lingering thermal pain
  • spontaneous unstimulated pain
  • referred pain
  • biologic basis
    • pulp contains 2 types of nociceptors
      • type A myelinated (preferentially located around pulp periphery)
      • type C nonmyelinated and smaller (preferentially located in blood vessels in central area of pulp)
    • C fibre activation indicates severe pulpal inflammation
      • deep dull quality, poorly localised, lingering pain
    • accumulation of inflammatory mediators: nociceptor sensitiation
      • spontaneous pain, sleep disturbance
    • TTpercussion + vital pulp: inflammation extends to periodontium
    • referred pain indicated severe inflammation and irreversible pulpitis
• asymptomatic irreversible pulpitis
  • vital inflamed pulp incapable of healing
  • no symptoms but irreversible inflammation still caused by carious exposure, caries excavation etc.
  • e.g. routine bitewing shows large carious lesion in pulp but no symptoms
• pulpal necrosis
  • negative pulp test (thermal/electric)
• previously treated
  • endodontically treated and canals obturated
• previously initiated therapy
  • partial endodontic therapy (e.g extirpation or pulpotomy)

Periapical diagnosis

• Normal apical tissues
• Symptomatic apical periodontitis (SAP)
  • acute inflam of PA tissues
  • TTPercussion, TTPalpation, pulp inflamed or necrotic, radiographically normal or apical radiolucency
  • 
  • example patient: strong persistent pain localised 36, exacerbated cold stimuli, affecting her sleep, painful to percussion
  • DIAGNOSIS: symptomatic irreversible pulpitis and symptomatic apical periodontitis
• asymptomatic apical periodontitis (AAP)
  • delicate equilibrium between microorganisms and host defence
  • asymptomatic (not TTP TPP), necrotic pulp, PA radiolucency
  • 
  • no pain, 22 and 23 no TTpalpation or TTpercussion, radiograph shows PARL, 22 nonresponsive to cold test
  • DAIGNOSIS: pulp necrosis + asymptomatic apical periodontitis
  • cant determine histology from radiograph or clinically Nair et al 1996
• acute apical abscess (AAA)
  • swelling, intense pain
  • +- systemic signs
  • necrotic pulp, TTP, increased mobility
  • radiographically widened PDL or radiolucency
  • two distinct presentations
  • cellulitis
    • initial presentation of infection
    • spreading inflammatory exudate (no pus)
    • large diffuse swelling, soft to palpate (initially)
    • dangerous (host unable to lcoalise the lesion)
  • abscess
    • more chronic (days to weeks)
    • pus surrounded by granulation tissue
    • well-localised fluctuant swelling
  • 
  • acute facial swelling and PARL on 22
  • DIAGNOSIS: Pulp necrosis + acute apical abscess
• chronic apical abscess (CAA)
  • abscess that drains to a surface (oral mucosa, facial skin, gingival sulcus via PDL)
  • sinus tract present, usually asymptomatic, necrotic pulp, periapical radiolucency
  • 
  • negative response to cold test, abscess associated with MB root of tooth 16
  • pulp necrosis and chronic apical abscess
• condensing osteitis (CO)
  • variant of AAP resulting in increased trabecular bone
  • pulp chronically inflamed or necrotic
  • young and middle aged patients
  • mandibular first molar
  • diffuse radiopaque lesion at apex of a tooth
  • expected to resolve after endodontic treatment
  • 
  • negative response to sensibility testing, increased radiopacity with distal root of tooth
  • necrotic pulp with condensing osteitis
• non endodontic pathosis (NEP)

case example

• draining sinus tract traces with GP point to apical radiolucency associated with MB root
• 16 is previously endodontically treated
• diagnosis: previously treated with chronic apical abscess