牙体牙髓病诊断学ppt课件

1、DIAGNOSIS IN ENDODONTICS PRIYA CHAND, M.S.DDEPT. OF ENDODONTICSDIAGNOSIS Diagnosis is an art. It involves learning skills of evaluation and knowing how to interpret the responses that the clinician receives from the patient. Even for the finest clinician, there will be times when the diagnosis is in

2、 doubt. In those instances, it is best to postpone initiating treatment. Symptoms will usually localize.OBJECTIVES OF A DIAGNOSISTo determine need for appropriate treatment (does this require endo, perio intervention etc.)To determine those cases deemed to be too complex for the level of training ,

3、experience and expertise of the practitionerTo determine if it is necessary to consult or refer to other health professionalsDIAGNOSTIC TESTSThermal testElectric Pulp TestSinus Tract TracingRadiographsSelective anesthesiaPercussionPalpationPeriodontal probingSYSTEM OF DIAGNOSISRadiographic examinati

4、onperiapical changesperiodontaladjacent teethCariesDetermine pathosis and potential etiology DIAGNOSISRADIOGRAPHIC EVALUATIONKnow normal structuresIf pulp tests vital, PA lesion could be normal landmark or other type of pathologyMultiple films from different anglesPA lesion should remain at apex reg

5、ardless of angleDIAGNOSIS RADIOGRAPHSBrynolf, Swed Dent J, 1970Correct diagnosis from single x-ray: 74% of casesCorrect diagnosis from 3 x-rays at different angles: 90% of casesA good quality radiographic image is essential RADIOGRAPHSBender, Seltzer, JADA, 1961Lesions in cancellous bone cannot be d

6、etected radiographically. The lesion can be detected when there is erosion or perforation of inner cortical bone Pulp can be necrotic with no PA lesionEarly stagesCortical bone must be involved to be visibleRADIOGRAPHIC EVALUATIONKnow normal structuresIf pulp tests vital, PA lesion could be normal l

7、andmark or other type of pathologyMultiple films from different anglesPA lesion should remain at apex regardless of anglePulp can be necrotic with no PA lesionInner Cortical bone must be involved for a lesion to be visible PULP VITALITY TESTSThermal testsCold TestHeat Test ELECTRIC PULP TESTINGPULP

8、VITALITY TESTINGGoal: Replicate the symptom !In what order should I test the teeth?Test the suspicious tooth last !Remember that these tests are comparison tests. You have to test the adjacent and contra-lateral teethDont forget to investigate the opposing arch.PERIODONTAL ASSESSMENTPERIODONTAL PROB

9、INGDIAGNOSISPULPALNormalReversible pulpitisIrreversible pulpitisNecroticPrevious Root canal therapy (previously treated)Previously intiated root canal therapyPERIAPICALNormal Periapical tissuesSymptomatic Apical periodontitisAsymptomatic apical periodontitisAcute apical abscessChronic apical abscess

10、Defining Diagnostic TermsPreviously Treated A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials, other that intracanal medicaments. Previously Initiated Therapy A clinical diagnostic category indicating

11、that the tooth has been previously treated by partial endodontic therapy (i.e. pulpotomy, pulpectomy).Symptomatic apical periodontitis Inflammation, usually of the apical periodontium, producing clinical symptoms including painful response to biting and percussion. It may or may not be associated wi

12、th 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.Chronic apical abscess: Hallmark sinus tract #20 PULPAL: Necrotic PERIAPICAL: Asy

13、mptomatic apical periodontitis# 7 PULPAL: Previous root canal therapy PERIAPICAL: Symptomatic apical periodontitis# 3 PULPAL: Irreversible pulpitis PERIAPICAL: Symptomatic apical periodontitis#14 PULPAL: Previous root canal therapy PERIAPICAL: Chronic periapical abscess # 25 # 26RESORPTIONINTERNAL /

14、 EXTERNAL RESORPTIONINTERNAL RESORPTIONUsually asymptomaticIf pulp is vital, resorption is active“Pink tooth is common name but tooth may not be pinkCause is thought to be impact traumaRadiograph : Outline of canal is distortedRCT is only hope of stopping resorptionRADIOGRAPHIC INTERPRETATIONINTERNA

15、L RESORPTIONINTERNAL RESORPTION #30 CALCIFIC METAMORPHOSISCondition follows trauma, particularly luxation CALCIFIC METAMORPHOSIS DIAGNOSISIf inconclusive or contradictory findingsReferIts OK to say “I cant tell exactly where the problem is at this point. Lets put you on this medication for pain and

16、let me see you again in 24-48 hours. Symptoms will often localize and we can accurately pinpoint the correct tooth or problem.Often one or two days will make a difficult diagnosis an easier one.DIAGNOSIS AFFECTS THE TREATMENT PLAN CLINICAL DATA SHEETForm that helps in facilitating complete and accur

17、ate documentationVITALITY TESTS or PULP TESTSTHERMAL TESTS VITALITY TESTSVarious methods and materials have been used to test the pulps response to thermal stimuli.It becomes important to differentiate a normal from an abnormal response to these pulp tests.Normal Response to Pulp TestingBaseline or

18、normal response to either hot or cold is a patients report that a sensation is felt but disappears immediately upon removal of the thermal stimulus.An Abnormal response to Pulp testing An abnormal response would include :A lack of response to stimulus (means necrotic)Lingering or intensification of

19、a painful sensation after the stimulus is removed (irreversible pulpitis)An immediate, excruciating painful sensation as soon as the stimulus is placed upon the tooth. (irreversible pulpitis)Most common Primary Pulp test Performed is the Cold test To be most reliable, cold testing should be used in

20、conjunction with the Electric Pulp tester (EPT)When is the Heat testing most useful ?When the patients chief complaint is intense dental pain upon contact with any hot liquid or food.Heat testing is performed by applying heated gutta percha or compound stick to the buccal surface of the teeth.Import

21、ant : a light layer of lubricant (Vaseline) should be applied onto the tooth surface to be tested prior to applying the heated material to prevent the hot gutta percha or compound from adhering to the dry tooth surface.COLD TESTINGCOLD TESTINGCotton tip applicator or Cotton Pellet ?Cotton pellet in

22、place with the cotton pliersCotton tip applicatorPROPER TECHNIQUE FOR PULP TESTING Important points to keep in mind The teeth should be isolated and the oral soft tissue should be protected with a 2 by 2 gauze or cotton roll.Cold testing is most effective when the spray is applied to the tooth on a

23、large # 2 cotton pellet. VIDEO ON PULP TESTING TO FOLLOW ELECTRIC PULP TESTINGThe EPT has limitations in providing information about vitality of the pulp. What does pulp response to electric testing (EPT) indicate?A response by the pulp to the electric current only denotes that some viable nerve fib

24、ers are present in the pulp and are capable of responding.TECHNIQUE: Imp StepsProper use of the electric pulp tester requires that the teeth to be evaluated must be isolated and dried.A controlled tooth of similar tooth type and location in the arch should be tested first in order to establish a bas

25、e line response.The suspected tooth should be tested at least twice to confirm the results.Can a Cold Test be Performed on a Crowned tooth or through a Bridge ?YESa cold test can be performed on a Crowned tooth and a Bridge ! NEXT QUESTION.Endo Ice and / or EPT ?Cotton tip applicator or Cotton pelle

26、t ?Cold Test with Endo Ice and Cotton Pellet Always Use a Cotton pellet for testing through a Crown or Bridge !Endodontic Treatment PlanningPulpal and Periapical DiagnosesDetermine the PrognosisDATA COLLECTIONChief ComplaintMedical and Dental HistoryClinical ExamExtra-oral: Fever, lymphadenopathyInt

27、ra-oral:Percussion, palpation, probing, mobilityCold test and EPTPROBLEM LISTDental Caries Periradicular lesionsSwelling Microleakage (long-standing temporization)Sinus tracts, discolorationTrauma, Cracks or fractures Attrition, abrasion, erosionNon-healing of previous endodontic treatmentCongenital

28、 anomalies of teethCRITERIA FOR ENDODONTIC TREATMENT PLAN SEQUENCING* Treatment plan phases:- Emergency treatment Disease ControlMaintenance and monitoringRestoration and reconstructionPhase IPhase II ROUTINE ROOT CANALTREATMENT PROCEDURESPulpectomy / Root Canal TreatmentAccess preparationWorking le

29、ngthRoot canal preparationRoot canal ObturationRestoration of the toothRecall and follow-up Retention of coronal restoration Establishing an adequate foundation Evidence of coronal microleakage necessitates retreatment before restorationFailure of Previous Endodontic TreatmentRETREATMENT VS. ROOT END SURGERYQuality of previous treatmentCoronal leakageRestoration to be replacedPossible etiologic factor that coul