ENDODONTICS: DIAGNOSIS FLOW CHART

Thermal symptoms, sharp pain Pulpitis Ache, pain to bite and/or chew Infected canal

Reversible Irreversible Acute Chronic

Root canal condition

Periapical condition

Necrotic and infected Pulpless and infected Previous endo treatment and infected

Apical periodontitis Apical abscess Apical cellulitis Except facial cellulitis Acute Chronic

Apical periodontitis also?

Acute Chronic

1 2

POSSIBLE CAUSES Trauma: luxation, avulsion, fracture Short duration: cutting/drying during dental procedures Longer duration: caries, restoration leakages, cracks, PD disease, chemical irritation DIAGNOSIS Diagnostic tests Percussion, palpation PA involvement Mobility perio Radiographic examination Biting Transillumination cracks Pulp sensibility tests (nerve response) NB sensitivity is when v responsive to stimulus Electric CO2 / cold Heat normal pulp wont respond to heat

TREATMENT OPTIONS Do nothing Extract Retreatment

PULPITIS Thermal symptoms Sharp pain Reversible Sharp, mild or moderate Extreme T changes Short duration (secs / stimulus removed) Tx: remove cause, Ledermix, restore, monitor Irreversible Short + sharp, aches after Mild T changes Lingering (5-10 mins) Spontaneous Wakes at night Worse lying down

Acute Chronic Severe pain Mild pain Short time (days) Present long time (weeks, months) Most common INFECTED CANAL Dull ache/throbbing On/off or continuous Pain to bite and chew TTP ROOT CANAL CONDITION Necrotic and infected No response to pulp sensibility tests Check history e.g. trauma Recent problem No PA radiographic changes Pulpless and infected No response to pulp tests Longer problem PA radiolucency (has already been pulpless 1-2 months) Previous endo treatment and infected History or radiographic signs of treatment PA radiolucency

PA CONDITION Apical periodontitis Pain to bite and chew V TTP

Apical abscess Localised collecting of pus Swelling Fever Chronic: draining sinus

Facial cellulitis Spreading infection through face Pus Swelling Fever

Acute Pain Short time

Chronic Nil/mild pain Long time 2 Not first time Radiolucency Widened PDL spaces

1 First time No radiolucency or slight thickening of PDL

CASE EXAMPLES FROM PREVIOUS YEAR Case 1 12yr old girl Sensitive to hot/cold drinks/food Pain started suddenly; now severe: aches for 1-2hrs No TTP CO2: 47(+++), 46 (+) Case 2 50yr-old male Increasing pain for 2 days; kept awake at night Pain with cold drinks & rinsing with tap water Sharp initially o Then a dull ache Lasts for 30-40minutes Case 3 20 yr old girl Sometimes sensitive to very cold drinks & icecream o Lasts 2-3 seconds Pain for several weeks No tenderness to percussion What is your diagnosis? Tooth: 47 Pulp: acute irreversible pulpitis PA tissues: normal (roots not fully developed) Cause: caries (radiographically) What treatment do you recommend? What is your provisional diagnosis? Acute irreversible pulpitis Which tooth is the most likely to cause the pain? 25 Why this tooth and not the other teeth? 26 has calcified canals + pulpotomy (wouldnt respond to temperature change) What tests do you recommend? Heat/cold tests (because sensitive to cold) What is your provisional diagnosis? Tooth: 37 Pulp: chronic reversible pulpitis PA tissues: clinically normal Cause: caries Why? Pain doesnt linger and is to extreme temps: rev. Has been there for several weeks: chronic No TTP: healthy PA tissues How can you confirm this diagnosis? Cold testing Radiographs Mobility tests, palpation, perio probing (examination) What is your provisional diagnosis? Tooth: 26 Pulp: infected root canal system PA tissues: chronic apical periodontitis Cause: marginal breakdown of restorations What treatment would you recommend? Re-treatment; extraction; nothing

Case 4 41-yr-old male No symptoms noted Routine PA radiograph taken during a periodontal examination No dental treatment for ~10yrs Periodontal probing: 3-5mm all sites CO2 : 24(+) 25(+) 26(-) 27(+) Percussion/palpation all normal Case 5 42-yr-old female Hot/cold sensitivity Pain started suddenly, now severe No TTP CO2: 24(+), 25(+++), 26(+), 27(+) History of perio treatment for the past 8 years

What is your provisional diagnosis? Tooth: 25 Pulp: acute irreversible pulpitis PA tissues: clinically normal Cause: concurrent marginal periodontitis Why is this your diagnosis? Radiolucency + CO2 results: 25 Spontaneous, severe: acute pulpitis No TTP: healthy PA tissues

Case 6 11-yr-old girl CO2: 74(+), 75(+), 36(-) No TTP, palpation No periodontal pockets

Case 7 64-yr-old female Sensitive to hot/cold food/drink Kept awake last night Not TTP CO2: 14(+), 15(+++), 16(-), 17(+) 2yrs ago: 14, 15 crowns; 16, 17 amalgams

Case 8 47-yr-old male RCF 3 days ago No pain before RCF appt Reason for endo tx: pulpless & infected canal with chronic apical periodontitis 16 now TTP CO2: 14(+), 15(+), 16(-), 17(+) Case 9 20-yr-old female Trauma at 10yrs RCFs 7yrs ago Post/crowns placed 1yr ago 21 TTP, labial swelling No perio pockets CO2: 12(+), 22(+), 23(+) Case 10 17-yr-old male Trauma to 51, 61 at 4 yrs No problems since Had ortho tx CO2: 12(+), 11(+), 21(+), 22(+) EPT: 12(21), 11(24), 21(30), 22(27) Discoloured 11, 21 Normal mobility No perio pockets

What are your observations? Mixed dentition, lower left posterior Open apices Pulpotomy PA radiolucencies of 36 What is your provisional diagnosis? Pulp: 36: pulpless and infected; previous pulpotomy PA tissues: chronic apical periodontitis What are your radiographic observations? Widening of PDL space around 14, 15 o High crowns = traumatic occlusion = mobility o Multiple teeth apical periodontitis No canals visible in 16: calcified What is your provisional diagnosis? Tooth: 15 Pulp: acute irreversible pulpitis PA tissues: clinically normal Cause: breakdown of restoration What is your provisional diagnosis? Tooth: 16 Pulp: Pulpless and root filled PA tissues: secondary acute apical periodontitis Cause: RCF material extruded through apex How would you manage this problem? Prescribe anti-inflammatories, or analgesics; depending on pain level Do not remove RCF: couldnt remove cement so problem would worsen What is your provisional diagnosis? Tooth: 21 Pulp: unsatisfactorily root filled and infected PA tissues: secondary acute apical abscess Cause: breakdown of restoration Why? Breakdown of previous restoration (huge radiolucency: takes >1yr to develop) What is your provisional diagnosis? Tooth: 11, 21 Pulp: clinically normal PA tissues: clinically normal Cause: ortho treatment caused formation of extra dentin, making the teeth turn yellow Management Monitor, review in 3yrs

Case 11 51-yr-old male Sensitive to cold Sometimes spontaneous pain Cant use tap water 26 slightly TTP 26 increased mobility Generalised perio disease CO2: 24(+), 25 (+), 26(+++), 27(+)

What is your provisional diagnosis? Tooth: 26 Pulp: acute irreversible pulpitis PA tissues: chronic apical periodontitis Cause: restoration breakdown What further information is required? Another PA (cant see all roots) Nature/duration of pain State of restoration Cracks/caries Management: Investigate; then endo tx if required