牙体牙髓病诊断学

DIAGNOSISINENDODONTICS

PRIYACHAND,DEPT.OFENDODONTICSDIAGNOSISDiagnosisisanart.Itinvolveslearningskillsofevaluationandknowinghowtointerprettheresponsesthattheclinicianreceivesfromthepatient.Evenforthefinestclinician,therewillbetimeswhenthediagnosisisindoubt.Inthoseinstances,itisbesttopostponeinitiatingtreatment.Symptomswillusuallylocalize.OBJECTIVESOFADIAGNOSISTodetermineneedforappropriatetreatment(doesthisrequireendo,periointerventionetc.)Todeterminethosecasesdeemedtobetoocomplexfortheleveloftraining,experienceandexpertiseofthepractitionerTodetermineifitisnecessarytoconsultorrefertootherhealthprofessionalsThermaltest01ElectricPulpTest02SinusTractTracing03Radiographs04Selectiveanesthesia05Percussion06Palpation07Periodontalprobing08DIAGNOSTICTESTSSYSTEMOFDIAGNOSISRadiographicexaminationperiapicalchangesperiodontaladjacentteethCariesDeterminepathosisandpotentialetiologyREVIEWONESTRUCTUREATATIMEDIAGNOSIS

RADIOGRAPHICEVALUATIONKnownormalstructuresIfpulptestsvital,PAlesioncouldbenormallandmarkorothertypeofpathologyMultiplefilmsfromdifferentanglesPAlesionshouldremainatapexregardlessofangleDIAGNOSISRADIOGRAPHSBrynolf,SwedDentJ,1970Correctdiagnosisfromsinglex-ray:74%ofcasesCorrectdiagnosisfrom3x-raysatdifferentangles:90%ofcasesAgoodqualityradiographicimageisessentialBender,Seltzer,JADA,1961RADIOGRAPHSBender,Seltzer,JADA,1961Lesionsincancellousbonecannotbedetectedradiographically.ThelesioncanbedetectedwhenthereiserosionorperforationofinnercorticalbonePulpcanbenecroticwithnoPAlesionEarlystagesCorticalbonemustbeinvolvedtobevisibleRADIOGRAPHICEVALUATIONKnownormalstructuresIfpulptestsvital,PAlesioncouldbenormallandmarkorothertypeofpathologyMultiplefilmsfromdifferentanglesPAlesionshouldremainatapexregardlessofanglePulpcanbenecroticwithnoPAlesionInnerCorticalbonemustbeinvolvedforalesiontobevisiblePULPVITALITYTESTS

ThermaltestsColdTestHeatTestELECTRICPULPTESTING

DoesnotmeasuredegreeofhealthordiseaseinpulpYesorNoresponseResultsmustbecomparedtootherteethFalsepositive--Largemetalrestoration,wettooth,touchinggingivaFalseNegative--Deadbattery,nolipclip,lipdry,poorcontactwithtoothPULPAL“A”fibersrespondtostimulusManyvariablescanaffectresponsewithEPT:enamelthickness,positionofprobe,calcification,patientanxiety,toothwithopenapexPULPVITALITYTESTINGInwhatordershouldItesttheteeth?Goal:Replicatethesymptom!01Rememberthatthesetestsarecomparisontests.Youhavetotesttheadjacentandcontra-lateralteethDon’tforgettoinvestigatetheopposingarch.Testthesuspicioustoothlast!02PERIODONTALASSESSMENT

PERIODONTALPROBINGDIAGNOSISPULPALNormalReversiblepulpitisIrreversiblepulpitisNecroticPreviousRootcanaltherapy(previouslytreated)PreviouslyintiatedrootcanaltherapyPERIAPICALNormalPeriapicaltissuesSymptomaticApicalperiodontitisAsymptomaticapicalperiodontitisAcuteapicalabscessChronicapicalabscessDefiningDiagnosticTermsPreviouslyTreated–Aclinicaldiagnosticcategoryindicatingthatthetoothhasbeenendodonticallytreatedandthecanalsareobturatedwithvariousfillingmaterials,otherthatintracanalmedicaments.PreviouslyInitiatedTherapy–Aclinicaldiagnosticcategoryindicatingthatthetoothhasbeenpreviouslytreatedbypartialendodontictherapy(i.e.pulpotomy,pulpectomy).Symptomaticapicalperiodontitis–Inflammation,usuallyoftheapicalperiodontium,producingclinicalsymptomsincludingpainfulresponsetobitingandpercussion.Itmayormaynotbeassociatedwithanapicalradiolucentarea.Asymptomaticapicalperiodontitis–Inflammationanddestructionofapicalperiodontiumthatisofpulpalorigin,appearsasanapicalradiolucentareaanddoesnotproduceclinicalsymptoms.Chronicapicalabscess:Hallmark‘sinustract’SINUSTRACTTRACINGTracewithGuttaperchapoint.IfEndolesion,itshouldleadtoapexofinvolvedtooth.Tractmayemanatefromatoothwhichisoneortwoteethawayfromtract.(#35GPcommonlyused)#20PULPAL:Necrotic

PERIAPICAL:Asymptomaticapical

periodontitis#7PULPAL:Previousrootcanaltherapy

PERIAPICAL:Symptomaticapical

periodontitisperiodontitisPERIAPICAL:Symptomaticapical#3PULPAL:Irreversiblepulpitis#14PULPAL:Previousrootcanaltherapy

PERIAPICAL:Chronicperiapical

abscess#25#26RESORPTIONINTERNAL/EXTERNAL

RESORPTIONRadiographicexamination

essentialclinicalelementindiagnosisofresorptivelesionsRESORPTION:Pathologicprocessthatresultsinthelossofsubstance

fromtheroot.ExternalRootResorptionInitiatedinthePDLandaffectstheexternalorlateralsurfaceoftheroot.InternalRootResorption

,Bell1830Initiatedwithintheradicularspace.

INTERNALRESORPTIONUsuallyasymptomaticIfpulpisvital,resorptionisactive“Pinktooth”iscommonnamebuttoothmaynotbepinkCauseisthoughttobeimpacttraumaRadiograph:OutlineofcanalisdistortedRCTisonlyhopeofstoppingresorptionRADIOGRAPHICINTERPRETATIONINTERNALRESORPTIONINTERNALRESORPTION

#30CALCIFICMETAMORPHOSISConditionfollowstrauma,particularlyluxation

Clinically,yellowdiscolorationoftheclinicalcrownExtensive,progressivecalcificationwhichradiographicallyobliteratesthepulpspace

Characterizedbydepositionofhardtissuewithintherootcanalspace

Commonlyseeninthedentalpulpaftertraumaticinjuryandisrecognizedasearlyas3monthsafterinjury,inmostcasenotdetectedforabout1yearCALCIFICMETAMORPHOSIS DIAGNOSISIfinconclusiveorcontradictoryfindingsReferIt’sOKtosay“Ican’ttellexactlywheretheproblemisatthispoint.Let’sputyouonthismedicationforpainandletmeseeyouagainin24-48hours.Symptomswilloftenlocalizeandwecanaccuratelypinpointthecorrecttoothorproblem.”Oftenoneortwodayswillmakeadifficultdiagnosisaneasierone.DIAGNOSISAFFECTSTHETREATMENTPLANCLINICALDATASHEET

FormthathelpsinfacilitatingcompleteandaccuratedocumentationVITALITYTESTSorPULPTESTSTHERMALTESTSVariousmethodsandmaterialshavebeenusedtotestthepulp’sresponsetothermalstimuli.01Itbecomesimportanttodifferentiateanormalfromanabnormalresponsetothesepulptests.02VITALITYTESTSNormalResponsetoPulpTestingBaselineornormalresponsetoeitherhotorcoldisapatient’sreportthatasensationisfeltbutdisappearsimmediatelyuponremovalofthethermalstimulus.AnAbnormalresponsetoPulptestingAnabnormalresponsewouldinclude:Alackofresponsetostimulus(meansnecrotic)Lingeringorintensificationofapainfulsensationafterthestimulusisremoved(irreversiblepulpitis)Animmediate,excruciatingpainfulsensationassoonasthestimulusisplaceduponthetooth.(irreversiblepulpitis)MostcommonPrimaryPulptestPerformedistheColdtestTobemostreliable,coldtestingshouldbeusedinconjunctionwiththeElectricPulptester(EPT)WhenistheHeattestingmostuseful?Whenthepatient’schiefcomplaintisintensedentalpainuponcontactwithanyhotliquidorfood.Heattestingisperformedbyapplyingheatedguttaperchaorcompoundsticktothebuccalsurfaceoftheteeth.Important:

alightlayeroflubricant(Vaseline)shouldbeappliedontothetoothsurfacetobetestedpriortoapplyingtheheatedmaterialtopreventthehotguttaperchaorcompoundfromadheringtothedrytoothsurface.COLDTESTINGCOLDTESTING

CottontipapplicatororCottonPellet?

Jones,Rivera,andWalton,JEndo,2002

Cottontipapplicatorrelativelyineffective

UseCottonpellet!CottonpelletinplacewiththecottonpliersCottontipapplicatorPROPERTECHNIQUEFORPULPTESTING

ImportantpointstokeepinmindTheteethshouldbeisolatedandtheoralsofttissueshouldbeprotectedwitha2by2gauzeorcottonroll.Coldtestingismosteffectivewhenthesprayisappliedtothetoothonalarge#2cottonpellet.VIDEOONPULPTESTINGTOFOLLOW

ELECTRICPULPTESTING

TheEPThaslimitationsinprovidinginformationaboutvitalityofthepulp.Whatdoespulpresponsetoelectrictesting(EPT)indicate?Aresponsebythepulptotheelectriccurrentonlydenotesthatsomeviablenervefibersarepresentinthepulpandarecapableofresponding.TECHNIQUE:ImpStepsProperuseoftheelectricpulptesterrequiresthattheteethtobeevaluatedmustbeisolatedanddried.Acontrolledtoothofsimilartoothtypeandlocationinthearchshouldbetestedfirstinordertoestablishabaselineresponse.Thesuspectedtoothshouldbetestedatleasttwicetoconfirmtheresults.CanaColdTestbePerformedonaCrownedtoothorthroughaBridge?NEXTQUESTION…..EndoIceand/orEPT?CottontipapplicatororCottonpellet?YES

acoldtestcanbeperformedonaCrownedtoothandaBridge!ColdTestwithEndoIceandCottonPelletAlwaysUseaCottonpelletfortestingthroughaCrownorBridge!EndodonticTreatmentPlanningPulpalandPeriapicalDiagnosesDeterminethePrognosisDATACOLLECTIONChiefComplaintMedicalandDentalHistoryClinicalExamExtra-oral:Fever,lymphadenopathyIntra-oral:Percussion,palpation,probing,mobilityColdtestandEPTPROBLEMLISTDentalCariesPeriradicularlesionsSwellingMicroleakage(long-standingtemporization)Sinustracts,discolorationTrauma,CracksorfracturesAttrition,abrasion,erosionNon-healingofpreviousendodontictreatmentCongenitalanomaliesofteethCRITERIAFORENDODONTICTREATMENTPLANSEQUENCING*Treatmentplanphases:-Emergencytreatment

DiseaseControlMaintenanceandmonitoringRestorationandreconstructionPhaseIPhaseII

ROUTINEROOTCANALTREATMENTPROCEDURESPulpectomy/RootCanalTreatmentAccesspreparationWorkinglengthRootcanalpreparationRootcanalObturationRestorationofthetoothRecallandfollow-upELECTIVEENDODONTICTREATMENTORRETREATMENTRetentionofcoronalrestorationEstablishinganadequatefoundationEvidenceofcoronalmicroleakagenecessitatesretreatmentbeforeresto