Diagnosis & case selection in endodontics

prepared by Dr.Rupak A. Mansoor

Introduction
Endodontic: is the branch of dentistry concerned
with morphology, physiology and pathology of human dental pulp and periradicular tissue. The aims of root canal treatment are to disinfect the root canal system completely obturate the space created so as to in tomb any microbes and to prevent re-infection with out causing any iatrogenic damage.

Endodontic diagnosis
The purpose of a diagnosis is to determine what problem the patient is having and why the patient is having that problem. This will directly relate to what treatment if any will be necessary.

Chief complain
Pain Swelling Loose tooth Broken tooth Discoloured tooth.

Chief complain
When did the problem (pain) begin? Description of pain(local.diffuse ) Character of pain (sharp,dull,throbing) Duration of pain(do the symptom subside shortly or do they remain after they are provoked) Aggravating factor Relieving factor

Medical History
Rheumatic fever Artificial heart valve Coronary artery disease Hypertension Diabetes Hepatitis blood disease. Prostheses HIV

Diagnostic examination and testing

Visual examination Digital examination Other test

Intraoral Extraoral

Palpation percussion Mobility test

Thermal pulp test Electric pulp test Bite test Selective anaesthesia Cavity test Transelumination test Laser Doppler test Pulse oximetry

Visual examination
Extraoral :like facial swelling, LN enlargment, etc... Face : the patient must be examined for asymmetry , localized swelling and change in color . Neck : LN enlargement.

Visual examination
Intraoral :swelling, discoloration of the crown of the tooth, sinus tract and etc... Oral swelling should be visualised and palpated to determine if they are diffuse or localised ,firm or fluctuant . Chronic sinus tract(fistulas) are important aids in diagnosis..they must be traced with gutta purcha to identified the site of origination.

Visual examination
Intraoral :crown fracture rarely revealed by XR examination, but visual examination and probing clarify the condition.

palpation
Certain clinical situation are primary evident only during palpation testing When per apical inflammation develop after pulp necrosis , the inflammatory process May burrow its way though facial cortical bone and begin to affect the overlying mucoperiosteum before incipient swelling become clinically evident.. It may be detected by gentle palpation by index finger. If amandibular tooth is abscessed its important to palpate submandibur area bimanually to determine whether any submandibular LN have been affected by the disease process the patients its responses to this palpation will indicate the extend of the disease process..

Percussion
This examination disclose the existence of an acute periapical inflammation . This test is simple to perform requiring only the butt end of a dental mirror handle used to tab gently the crown of the tooth..

Bite test
Tooth with periradicular periodontitis or having a crack are sensitive to this test .

Devices
1-Cotton applicators 2-Toothpicks 3-Orangewood 4-Rubber polishing wheel 5-Tooth slooth

Transillumination
Clinical importance
1-Necrotic pulp show darker shadow in compare to the rest of tooth. While viable pulp show no differences.
2-Teeth with radiolucencies reveal a shadow around the apex, whereas normal teeth show no difference in the area. 3-Helpful in diagnosing vertical fracture.

Thermal pulp testing

It is a reliable and easily performed diagnostic procedure. The equipment use for this test Is in expensive and easy to use.
One of the main resean why thermal pulp test is valuable diagnostic tool is that certain painful condition Of the pulp may be brought on or relieved by sudden severe temperature change.

So the temperature reaction after application of heat or cold to specific tooth not only pinpoint the involved tooth, but also strongly suggest the condition present.

Thermal pulp testing

Heat pulp test is done by heated gutta percha to elicit response to heat .as in all pulp testing the tooth to be treated is dried and walled off with cotton rolls, and saliva ejector is placed. A strip of material (7X7 mm) is cut, while being held in a cotton pliers, is heated to just short of smoking and applied to the cervical area of the tooth It left for. (5sec) or until the patient feel pain. A temp. greater than (65.5C) is developed , elicit response from abnormal or hyperemic pulp.

Thermal pulp testing

-Heated gutta percha for tooth without crown or deep restoration is useful . - Overheating the gutta percha can damage the pulp and causing unnecessary pain to the patient . the crown should be protected with petroleum jelly to prevent the heated gutta percha stick to the tooth.. -Cast crown are too thick to allow the heated gutta percha to raise the temperature of underline tooth structure sufficiently to react.

-if a hot test is needed on a tooth ( with full coverage ) , sufficient heat is produced by using a rubber wheel mounded on mandrel revolving at polishing speed against the precious metal .

Thermal pulp testing

The rubber wheel used on the lingual area of the crown , where the polishing not materially affect the shape of the casting , yet will be close enough to the more sensitive area of the tooth. Hot water bath. Are time consuming for the clinician , and they are superior in their accuracy. the use of worm water allow the entire crown to be immersed even when the tooth has been restored with full crown (metal and or porcelain) sufficient contact is made to allow warming of the pulp. The hot water bath prevent excessive temperature change damage the tooth.

Thermal pulp testing Procedure

Before proceeding the clinician should explain the procedure to the patient. And should Demonstrate the test on the several teeth on the cotralateral site as a control. The teeth to be tested should be isolated and dried before initiating the test by gauze to ensure accurate response. The blast of air should not be used to dry the tooth because room temperature can cause Thermal shock if the pulp is inflamed and it may spray saliva to assistant or to clinician.

Thermal pulp testing Cold test

Methods are
1- cold water bath 2- ethyl chloride 3- stick of ice 4- carbon dioxide ice

cold bath and ethyl chloride are the most commonly used . Cold water bath : it take time, but it illicit the most accurate patient response. After a tooth is completely isolated with a rubber dam, a plastic syringe is used to immerse the Tooth in ice water , although this test take a little more time , the benefit is that all the surface are submerged in the ice water , there for this is the most sensitive method for cold testing ..

 Where as cold causing fluid to contract producing out ward flow.the rapid movement of the fluid across the cell membrane of the sensory receptor deform the membrane and activate the receptor

Thermal pulp testing

Ethyl chloride spray: is used if no refrigerator is present in the office. a spray is directed at the cotton pellet held in pliers until the frosting is noted on the fiber. The pellet is then placed on the cervical area of the dried tooth and response is noted . the pellet is kept in contact with crown for 5 second or until the patient begin to feel the pain..
Stick of ice : seldom used because they may worm when applied to the tooth and leak on the gingiva causing with false positive response.

Thermal pulp test

Refrigerant spray

Thermal pulp testing

Carbon dioxide dry ice stick are extremely cold (-77.7 C) and may cause infarction line in enamel or damage to the other wise healthy pulp. Cold test using (CO2) snow or liquid refrigerant and heat test employing heated gutta percha or hot water activate hydrodynamic force within the dentinal tubule which inturn excite the interdental A-fiber. Cold test do not injure the pulp. Heat test has a greater potential to injure the pulp. But if the test is used properly the injury is less likely.

Response to thermal test

There are 4 possible response. 1- No response which indicate non vital pulp. also can indicate a false positive response because of excessive calcification , immature apex ,resent trauma and patient premedication 2- mild to moderate pain that subside within 1 to 2 second after the stimulus has been removed. a momentary mild to moderate pain is regarded as a normal .

Response to thermal test

3- strong momentary painful response that subside within 1 to 2 second or longer after the stimulus has been removed . A painful response that subside quickly is characteristic of reversible pulpitis.. 4- moderate to strong painful response for several second or longer after the stimulus have been removed. A painful response that linger after the stimulus is removed Is characteristic of irreversible pulpitis ..

Periodontal probing
The dentist should used a blunt calibrated probe to explore the integrity of the gingival sulcus around each tooth. Isolated area of vertical bone lose may be of an endodontic etiology.
The depth and direction of periodontal pocket can be confirmed through placement of a gutta percha or silver cone in a circular defect .

Mobility
Tooth mobility is directly proportional to the integrity of the attachment apparatus Or to the extend of inflammation of the periodontal ligament resulting from pulpal inflammation or degeneration. The clinician should use 2 mouth mirror handle to apply alternating lateral force in a facial lingual direction to observe the degree of mobility of the tooth..

The degree of depresablity of the tooth within its alveolus should also be tested by pressing the tooth in to its sulcus and watching for any vertical movement .

Mobility
Causes of tooth mobility : horizontal root fracture in the coronal halve of the tooth. Very resent trauma The pressure exerted by the purulent exudates of an acute apical abscess may cause some transient mobility of a tooth. This mobility is quickly relieved by the establishment of a drainage of the exudates .

Selective anesthesia test

The use of intra ligamentory anesthesia is an effective diagnostic tool in special clinical situation. When two teeth are considered to be possible etiological cause in patient with severe , lingering residual pain especially from thermal application but in able to make the final choice between these teeth.

Selective anesthesia test

Administration of 0.2% lidocaine in to a distal sulcus will provide relieve for the patient. If the patient still have strong , diffuse pain , administration of LA in to the distal sulcus of the offending tooth will briefly stop the pain .. but if the pain is not relieved by the administration of intraligamentory anesthesia , the clinician must considered non odontogenic etiology.

Test cavity
The use of a test cavity preparation is the final and an questionably the most accurate Of the pulp vitality test.

It involve the removal of dentin by a bur in a hand piece with out the use of LA to determine the vitality of an underline pulp. Because it remove sound tooth structure, and in most instances some portion of a restoration , this test should be performed only as a last resort.

Test cavity

For test cavity the preparation is placed in the lingual or palatal surface of anterior teeth or the occlusal surface of the posterior teeth . When dentine is drilled, the patient will know the pulp is vital even if he or she have a high enough threshold .

Laser Doppler flowmetry

Used to assess blood flow in microvascular system in the tooth..
This test are Accurate& Reliable But not used on routine bases in dental practice ..

Pulse oximetry
Used for pulp testing is designed to measure the oxygen concentration and the pulse rate Of the blood inside the pulp.

Electrical pulp test

Is designed to stimulate response of sensory fibers within the pulp by electrical excitation.. Dose not provide a bout the vascular supply to the pulp which is the true determination of the pulp vitality..

Electrical pulp test

Ideal situation of electrical pulp testing: In certain circumstances electrical pulp test has a high degree of accuracy A) On the anterior tooth has high degree of accuracy since the teeth are single rooted , are easy to isolate , and have a large restoration less than posterior tooth. And since good access available to reach cervical responsive area . B) Excellent evaluation of teeth in traumatic accidents is available with an electric pulp test.

Electrical pulp test

False positive result
1- electrode contact with metal restoration. 2- liquefaction necrosis may conduct current to the attachment apparatus leading the patient To rise his hand slowly near the highest range of current flow . 3- failure to isolate and dry the tooth.(saliva acts as a conductor)

Electrical pulp test

False negative result 1- the patient has been heavily premeditated with analgesic 2- recently traumatize tooth. 3- partial necrosis ( although the pulp is vital the apical halfe of the root , the absence of response to the electrical pulp test could appear to suggest that there is a total necrosis

Electric pulp testing procedure

1- tooth should be isolated and dried. 2- similar tooth should be tested as a control. 3-the result should be confirmed wisely. 4- the tip of testing probe must be coated with a water or petroleum based media.

Radiographs
Radiography is needed, rst as an aid to diagnosis, then periodically during treatment.

Radiographs
(1) aid in the diagnosis of hard tissue alterations of the teeth and periradicular structures; (2) determine the number, location, shape, size, and direction of roots and root canals. (3) estimate and conrm the length of root canals before instrumentation; (4) disclose unsuspected, pulp canals by examining the position of an instrument within the Root

Radiographs
(5) aid in locating a pulp that is markedly calcied and/or receded.

6) determine the relative position of structures in the facial lingual dimension;

(7) conrm the position and adaptation of the primary lling point. 8) aid in the evaluation of the nal root canal lling.

Radiographs
(9) aid in the examination of lips, cheeks, and tongue for fractured tooth fragments and other foreign bodies.
(10) evaluate, in follow-up lms, the outcome of endodontic treatment.

Technique

Radiographic parallelism. The long axis of the lm, the long axis of the tooth, and the leading edge of the cone are parallel and perpendicular to the x-ray central beam.

Technique

Mandibular molars. A, Central ray directed at right angle to lm positioned parallel to arch. B, Limited information is gleaned from radiograph because of superimposition of structures and canals.

Technique

Mandibular molars. A, Central ray directed at 20 degrees mesially to lm positioned parallel to arch. B, Two canals are now visible in both roots of the rst molar (black arrows). Open arrow indicates confusing root outlines.

Technique

Maxillary premolars. A, Horizontal right-angle projection produces illusion that maxillary rst premolar has only one canal. B, Varying horizontal projection by 20 degrees mesially separates two canals. Lingual canal is toward mesial.

Technique digital radiography

For sanitary reasons, the sensor is sheathed in a latex nger-cot.

The patient can readily see her clinical situation on the computer screen

Tomography
pulp spaces and roots will be visualized in the third dimension. Buccolingual curvatures will be evident, as well as the shape of the canal space and the location of the apical foramen .

Indication for root canal treatment

1- post space . A vital tooth may have insufficient tooth substance to retain a crown so the tooth may have to be root treated are restored with post retained crown . 2- over denture .decoronated teeth retained in the arch to preserve alveolar bone and provide support to removable processe . 3-teeth without doubtful pulps. Root treatment should be considerate for any tooth with doubtful vitality if it require an extensive restoration , particularly if its to be bridge a abutment. 4- pulp sclerosis following trauma . Diagnostic periapical radiographs should be taken for teeth which have been subject to trauma .

Contraindication for root canal treatment

1- non restorable tooth , any tooth that can not be restored to the functional and esthetically acceptable following endodontic treatment . Teeth with severe root caries and internally weaken tooth. 2- non strategic tooth , a tooth not in occlusion and not needed as a abutment. 3- vertical fracture . Through root structure have an almost hapless prognosis . 4- insufficient periodontal support. Unless good periodontal support is present to insure retention of tooth.

Contraindication for root canal treatment

5- massive resorption. Which may be either internal or external Varity, if the resorption is of extremely large dimension, with perforation. 6- canal not suitable for instrumentation . Sclerosed canal or severely curved canal. 7-Inadequate access. A patient with restricted opening or a small mouth may not allow sufficient access for root canal treatment . 8-Poor oral hygiene . 9- patient attitude . Unless the patient is sufficiently well motivated .

THANKS