DIAGNOSIS AND TREATMENT PLANNING

MUDASIR AHMAD LONEGURU NANAK DEV DENTAL COLLEGE AND

RESEARCH INSTITUTE SUNAM PUNJAB

BDS 4TH YEAR

DIAGNOSIS

• Diagnosis is defined as utilization of scientific knowledge for identifying a diseased process and to differentiate from other disease process

• Literal meaning of diagnosis is determination and judgement of variations from the normal .

• it is a procedure of :

• Accepting a patient

• Recognizing that he/she has a problem

• Determining the cause of the problem

• And developing a treatment plan which would solve the problem

TOOLS OF DIAGNOSIS

• KNOWLEDGE

• COMPASSION

• PATIENCE

• CURIOSITY

• MANAGEMENT

• LISTENING : ART OF LISTENING IS MOST IMPORTANT

AS IT ESTABLISHES A RAPPORT ,UNDERSATNDIND AND TRUST

FOUR STEPS OF DIAGNOSIS

• STEP I : Assemble all available facts gathered from • Chief complaint

• Medical and dental history

• Diagnostic tests

• Investigations

• STEP II : Analyze and interpret the assembled clues to reach the provisional diagnosis

• STEP III :Make differential diagnosis of all possible diseases which are consistent with signs ,symptoms and test results gathered .

• STEP IV : Select the closest possible choice

CASE HISTORY

• IT COMENSES BY ASKING THE PATIENTS FOR THE FOLLOWING DATA

• NAME• AGE/SEX• ADDRESS• OCCUPATION

• This above data helps in establishing a communication ,maintaining a record ,and understanding the economic status of the patient

CHIEF COMPLAINT

• it consist of information which promoted patient to visit a clinician ,they present certain symptoms that are indicative of an illness.

• Chief complaint should always be recorded in patients own words

HISTORY OF PRESENT ILLNESS

• it is a more descriptive elaboration of the chief complaint given by the patient .

• It should include • Signs and symptoms

• Duration and intensity of pain

• Relieving and exaggerating factors

NOTE

• if a chief complaint is toothache but symptoms are too vague to establish a diagnosis ,then analgesics should be prescribed to help patient tolerate pain until the toothache localizes.

• A history of persisting pain without exacerbation may indicate problem of nonodontogenic origins

• The most common tooth ache may arise from either pulp or periodontal ligament

• Pulpal pain may be sharp or dull ,pulp vitality tests are done to reach the diagnosis.

• Also pulpal pain may not be localized and it is mostly acute in nature.

• If pain originates from periodontal ligament ,then tooth will be sensitive to percussion ,chewing ,palpation .

MEDICAL HISTORY• Endodontic treatment is otherwise not contraindicated by any other medical

condition ,but some of them may require special care

• Scully and Cawson have given a checklist for the same.• ANAMIA• BLEEDING DISORDERS• CARDIORESPIRATORY DISORDERS• DRUG TREATMENT AND ALLERGIES• ENDOCRINE DISEASE FITS AND FAINTS• GASTROINTESTINAL DISORDERS• HOSPITAL ADMISSIONS AND ATTENDANCE • INFECTIONS • JAUNDICE• KIDNEY DISEASE• LIKELYHOOD OF PREGNANCY OR PREGNANCY

EXTRA ORAL EXAMINATION

• Patient should be looked for any facial asymmetry ,distention of tissues,localized swellings , any signs of trauma

• Size of pupil may signify systemic disease ,premedication or fear

• After examination of head and neck region ,one should go for extra oral palpation

• If any localized sweling is present then look for :

• Local rise in temperature

• Tenderness

• Extent of lesion

• Induration

• Fixity of underlying tissues

PALPATION OF SALIVARY GLAND

Extra oral palpation of submandibular gland by bimanual palpation

PALPATION OF TMJ

The index finger are placed in the pre auricular region ,the patient is asked to open the mouth and perform lateral excursion to notice

• Any restricted movement

• Deviation in movement

• Jerky movement • Clicking • Locking and

crepitus

PALPATION OF THE LYMPH NODES

The lymph nodes frequently palpated are • Pre auricular• Submandibular• Sub mental• Cervical

The lymph nodes are examined for any • Enlargement • Tenderness• Mobility• Consistency

INTRA ORAL EXAMINATION

• Check the degree of mouth opening : normally it should be at least two fingers.

• The following structures should looks upon systematically • The buccal , labial,and alveolar mucosa

• The hard and the soft palate

• The floor of the mouth and tongue

• The retromolar pad

• The posterior pharyngeal wall and facial pillars

• Salivary gland and orifices

GENERAL DENTAL STATERECORDING

• It includes :

• Oral hygiene status

• Amount and quality of restorative work

• Prevalence of caries

• Missing tooth

• Presence of soft and hard swellings

• Presence of any sinus tracts

• Discolored teeth

• Tooth wear and facets

PALPATION : Is done using digital pressure to check any tenderness in the soft tissue overlying suspected tooth .

SENSITIVITY may indicate iinflammation in the periodontal ligament

further palpation may give information regarding fluctuation or fixation or induration of soft tissues.

PERCUSSION OF TOOTH : Indicates inflammation in periodontal ligament which may be due to trauma ,sinusitis , or any PDL disease.

DEGREE OF RESPONSE TO PERCUSSION IS DIRECTLY PROPORTIONAL TO DEGREE OF INFLAMMATION

PERIODONTAL EVALUATION : assessed by palpation ,percussion, mobility , and probing .

MOBILITY OF TEETH : GRADE I: slight(normal)

GRADE II : moderate mobility within a range of 1 mm.

GRADE III : extensive movement (more than 1 mm) in mesiodistal or lateral direction combined with vertical displacement

in alveolus

PULP VITALITY TESTS

• Pulp testing is often reffered to as vitality testing

• It is important because: 1.determine the vitality of tooth

• 2.tells us about the pathological status of the pulp

• Various types of pulp tests performed are as follows:

a) Thermal tests: 1.cold test

2.heat test

b)electric pulp testing

c) test cavity

d) anesthesia testing

e)bite test

THERMAL TESTS

• In this test response to heat and cold is noted

• The basic principle for pulp to respond to thermal stimuli is that the patient reports sensation but it disappears immediately .

• ABNORMAL FINDINGS: 1.painful sensation even after removal of stimuli .

2. no response to the stimuli .

Two types cold test

heat test

COLD TEST

• Most commonly used test for assessing the vitality of tooth

• Can be done by several ways

• Use of rubber dam for isolation is mandatory with all types as when we use icesticks melting ice will run on to adjacent teeth and gingivae resulting in false positive result

• Various methods are as follows:

1. spray with cold water directed against the isolated tooth

2. application of cotton pellet saturated with ethyl chloride .the spray with ethyl chloride is also employed .as it evaporates so rapidly that it absorbs heat and cools the tooth.

3. the frozen carbon dioxide (dry ice) is a reliable method.The frozen carbon dioxide is available as sticks which is applied to the facial surface of the tooth .while testing precaution should be taken to properly isolate the soft tissue failing of which the carbon dioxide may come inn contact with the sift tissue causing burns.

ADVANTAGE OF USING DRY ICE

It can penetrate the full coverage restoration and can elicit a pulpal reaction to the cold because it of its very low temperature (-69 F TO -119 F/56 C to 98 C

5. wrap an ice piece in the wet gauge and apply on the tooth.

6. Dichlorodifluoromethane (Freon) and the recently available material

1,1,1,2- tetra fluoroethane are also used as cold testing material .

HEAT TEST• In patients complaining of intense pain on contact with hot object this test is of great

value . Various techniques used are as follows:

1. WARM AIR is applied to the patients exposed tooth surface

2. If a higher temperature is required to elicit a response then other options like heated stopping stick ,hot burnisher ,hot water ,etc can be used.

3. Heated gutta percha stick is commomly used method.the tooth is coated with petroleum jelly so that gutta percha does not stick to the surface .the heated stick is applied at the junction of cervical and middle third of facial surface of tooth and patients response is noted

4. The hot burnisher ,hot compound or any other heated instrument can be used for heat test .

5. use of frictional heat produced by rotating polishing rubber disc against the tooth surface.

6. Deliver warm water from a syringe .this is used especially with porcelain or full coverage restorations .

• The preferred temperature for heat test is 150 F (65.5 C).

• NORMAL RESPONSE: Mild transitory …indicating normal pulp

• ABNORMAL RESPONSE: PULP NECROSIS – absence of response in combination with other tests.

IRREVERSIBLE PULPITIS: exaggerated and lingering response .

FALSE NEGATIVE RESPONSE

• This is when tooth showed no response but the pulp could be possibly vital.

• Various conditions are :

1.Recently erupted teeth with immature apex due to incomplete development of plexus of Rashkow . Hence incapable of transmitting pain.

2. Recent trauma –injury to nerve supply at the apical foramen or because of inflammatory exudates around the apex may interfere with the nerve conduction

3. Excessive calcification may also interfere with the nerve conduction .

4.Patient is on premedication with analgesics and tranquillizers.

ELECTRIC PULP TESTING

• This is done by electrical excitation of neural elements within the pulp using an electric pulp tester.

• They can be battery operated or have a power plug source.

• A positive response shows pulp vitality ,negative response showas pulp necrosis and non vitality

PROCEDURE

• Isolation of teeth to avoid false positive response .2” x 2” gauge piece can be used for the same .

• An electrolyte is applied on the tooth electrode and placed on the facial surface of tooth .avoid contact with gingiva as it would give a false positive response .

• The circuit should be set like ;

• electrode tooth body electrode

• Current is slowly increased and patient is asked to point when the sensation occurs.

• It is done 2-3 times and average reading is noted

• If vitality of a tooth is in question ,the asdjacent tooth and the contralateral tooth can be tested upon as a control.

DISADVANTAGES

• Teeth having acute alveolar abscess may give false positive results,as the gaseous or liquefied products may transmit current.

• Multirooted tooth can have vitalitility variation in their pulp canals.

• False positive results in the following ;

• Recent trauma

• Recently erupted teeth with immature apex

• Patient with high pain threshold

• Calcified canals

• Poor battery used in the tester

• Extensive pulp protection bases

• Premedicated patients

• Partially necrosed tooth may be indicated as completely necrosed

TEST CAVITY

• Used when other methods are inconclusive

• Cavity preparation is done using high speed burs and adequate water coolant

• Anaesthesia is not given to the patient .

• The patient asked when the sensation or the pain is felt .

• The test is terminated by a restoration

• If the patient is insensitive to the procedure the drilling is continued till the pulp chamber is reached and it is then further proceeded for an endodontic treatment

ANESTHESIA TESTING

• Used when the patient is not able tto specify the site of pain ,and when other pulp testing methods are inconclusive.

• The main objective is to anesthetize a tooth at a time until the pain is eliminated

• An intraligamentary injection is given to the most posterior tooth in the suspected quadrant

• If pain persist even after anesthesia reapeat the procedure to the next teeth mesial to it..

• The opposite arch can also be included if the source of pain cannot be determined earlier in the previous arch

BITE TESTS

• This test helps when patient complains pain on mastication

• Biting causes pain when the pulpal necrosis has extended to the periodontal ligament space or if there is a crack on the tooth

• Patient is asked to bite on a hard object like cotton swab, tooth pick,orange wood stick with the suspected tooth and the contralateral tooth

• A tooth sloth is also used for this test .

• Pain dur to biting may indicate fractured tooth

RECENT ADVANCES

• LASER DOPPLER FLOWMETRY

works on the Doppler principle in which a low power light from a monochromatic laser beam of known wavelength along a fiber optic cable is directed to the tooth surface ,where the light passes along the direction of the enamel prisms and dentinal tubules to the pulp .

• Ø  Non invasive , electro optical technique , allows for semiquantitative recording for blood flow

• Ø  Incident laser beam of known wavelength is directed through crown of tooth  and Moving red blood cells cause frequency of laser beam to be shifted & some light to be back scattered out of tooth

• Ø  Reflected light is detected by photocell on tooth surface the output of which is proportional to the number & velocity on moving red blood cells

DISADVANTAGES OF LDF• Cannot be done in patients in which the tooth cant be stablised due to their

movements.

• Premedication may affect blood flow

• Requires higher technical skills

• Expensive

ADVANTAGES OF LDF

1.An objective test 2. Accurate to check pulp vitality

PULP OXIMETRY

• A pulp oximeter is a non invasive device oxygen saturation monitor in which liquid crystals display oxygen saturation ,pulse rate, plethysmographic wave from readings

• The probe consists of red and infra red light emitting diodes opposite a photoelectric detector

• Detection of pulse is enough for pulp vitality ,clinically

• Helpful in trauma cases in which nerve supply is injured ,but blood supply is intact

ADVANTAGES OF PULP OXIMETRY

• Objective method.no need for giving patient an unpleasant stimulus

• Pulpal circulation is evaluated independent of the gingival circulation

• Easy to reproduce pulse readings of the pulp

• Smaller and cheaper oximeter are noe available

DISADVANTAGES

Background absorption associated with venous blood

DUAL WAVELENGTH SPECTROPHOMETRY

• This method measures oxygenation changes in the capillary bed rather than the supply vessel and hence does not depend upon the pulsatile blood flow

• And also the presence of arterioles in the pulp and its rigid encapsulation by surrounding dentine and enamel make it difficult to detect a pulse in the pulp space.

• It is objective non invasive ,n it uses visible light which is filtered so eye procteection is not required.

• Can be used in avulsed and replanted teeth.

TRANS ILLUMINATION WITH FIBER OPTIC LIGHT

• System of illumination whereby light is passed through a finely drawn glass or plastic fibers by a process known as total internal reflection .

• DETECTION OF INTERLEUKIN - I BETA IN HUMAN PERIAPICAL LESION

PLETHYSMOGRAPHY

• It is a method of assessing the changes in volume and it records a wave form as a pressure pulse passes through the tooth

• Presence or absence of a wave decides its vitality status

CRACKED TOOTH SYNDROME

• It means incomplete fracture of tooth with a vital pulp.

• Causes: large and complex restoration

• Stressful lifestyle

• Parafunctional habits

• High masticatory forces

SIGNS AND SYMPTOMS• Erratic pain on mastication , with release of bitting

• Sensitivity to thermal changes

• Tooth is not tender on percussion .

DIAGNOSIS :

1. HISTORY OF PATIENT

History regarding dietary and parafunctional habits and history of any trauma

2. VISUAL EXAMINATION

Look for any wear facets and steep cusps

Check for any cracked restorations or unusual gaps between the restoration and the tooth .

3.TACTILE EXAMINATION

Pass the explorer gently ,it may catch a crack

• PERIODONTAL PROBING

• BITE TEST

• TRANSILLUMINATION

• USES OF DYES : METHYLENE BLUE -----------1.DIRECTLY APPLIED

• 2. MIXED WITH ZOE AND PLACED IN CAVITY

• RADIOGRAPHS

• SURGICAL EXPOSURE

CLASSIFICATION OF CRACKED TOOTH SYNDROME

• CLASS A - INVOLVING ENAMEL AND DENTIN BUT NOT PULP

• CLASS B - CRACK INVOLVING PULP BUT NOT PERIODONTAL APPARATUS

• CLASS C - CRACK EXTENDING TO PULP AND INVOLVING PERIODONTAL LIGAMENT

• CLASS D - COMPLETE DIVISION OF TOOTH WITH PULPAL AND PERIODON TAL APPARATUS INVOLVEMENT

• CLASS E – APICALLY INDUCED FRACTURE

TREATMENT OF CRACKED TOOTH SYNDROME

• Reduction of the occlusal contacts by selective grinding

• When crack involve the pulpal floor endodontic access is needed.but it should be chased down by a bur as it turns invisible long before it terminates.

• If crack is partially visible across the floor of the chamber ,the tooth may be bonded with a temporary crown or orthodontic band .

NORMAL RADIOGRAPHIC LANDMARKS

• ENAMEL: most radiopaque structure

• DENTIN: slightly darker than enamel

• CEMENTUM: similar to dentin in appearance

• PERIODONTAL LIGAMENT : appears as a narrow radiolucent line around the tooth .

• LAMINA DURA: it is a radiopaque line representing the tooth socket

• PULP CAVITY: pulp chamber and canals are seen as radiolucent lines within the tooth

PRINCIPLES OF RADIOGRAPHY

• There are two techniques for exposing the tooth

• 1. bisecting angle technique

• 2. paralleling technique

• BISECTING ANGLE TECHNIQUE

The x ray beam is directed perpendicular to an imaginary plane which bisects the angle formed by recording plane of x ray film and the long axis of the tooth .it can be performed without the use of film holders.

It is quick and comfortable but has certain disadvantages

DISADVANTAGES

• Incidences of cone cutting

• Image distortion

• Superimposition of anatomical structures

• Difficulty to produce the periapical films

PARALLELING TECHNIQUEThe x ray film is placed parallel to the long axis of the tooth to be exposed and the

x ray beam is directed perpendicular to the film .

ADVANTAGES

• Better accuracy of image

• Reduced dose of radiation

• Reproducibility

• Better images of bone margins ,interproximal regions and maxillary molar region.

DISADVANTAGESDifficulty to use in patients with shallow vault ,gag reflex.

• Cone angulation is one of the most important aspects of radiography because it affects the quality of image

• As the angle increases away from parallel ,the quality of image decreases .

• This happens because as the angle is increased ,the tissue that the x ray must pass through includes greater percentage of bone mass thus anatomy becomes less predictable

• To limit this problem ,Walton gave a modified paralleling technique in which central beam is orientated perpendicular to radiographic film but not to teeth .

• Modified technique is used in : shallow palatal vault , maxillary tori , extremely long roots ,uncooperative and gagging patient

CONE IMAGE SHIFT TECHNIQUE

• The main concept of technique I that as the vertical or horizontal angulations of x ray tube head changes ,the object buccal or closest to the tube head moves to opposite side of radiograph when compared to lingual object .

• When two objects and the film are in fixed position and the tube head is moved ,images of both objects moving in opposite direction ,the resultant radiograph shows lingual object that moved in the same direction as the cone and the buccal object moved in opposite direction .this is known as SLOB rule.

ADVANTAGES OF SLOB

Helps in separation of overlapping canals

Working length are better traced

Helps to locate root resorptive process in relation to tooth

Identification of anatomical landmarks and pathosis

Used to increase visualization of apical anatomy by moving anatomic landmarks such as zygomatic process or the impacted tooth

Advantageous in access opening as it helpd to identify the missed canals or calcified canals and sometimes the canal curvature

DISADVANTAGES

• It results in the blurring of object which is directly proportional to cone angle

• It causes superimposition of structures

Reversible pulpitis Asymptomatic or slight symptoms to thermal stimulus

No changes +ve response to vitality testing .

Irreversible pulpitis Asymptomatic or may have spontaneous or severe pain to thermal stimuli

No changes ,except in long standing cases condensing osteitis

Gives response

Pulp necrosis None Depends upon periapical status

No response

Acute apical periodontitis

Pain or biting or pressure Not significant Depending on status of pulp ,response or no response

Chronic apical periodontitis

Mild or none Not significant Depending on pulp status ,response or no response

Acute apical abcess Pain and /or swelling Radiolucency at apical end

No response

Chronic apical abcess Draining sinus Radiolucency No response

Condensing osteitis Varies according to status of pulp oe peri apex

Increased trabecular bone

Depending on pulp status response or no response

SYMPTOMS X RAY FINDINGS PULP VITALITY TESTS

RADIOGRAPHS

• Radiographs are one of the most important tools in making a diagnosis.

• Radiographs help us in the following way:• Establishing diagnosis

• Determining the prognosis of tooth

• Disclosing the presence and extent of caries

• Check the thickness of periodontal ligament

• Too see the presence or absence of lamina dura

• To look for any lesion associated with the tooth

• To see the number ,shape, length and pattern of the root canals

• To check if any obstruction present in the pulp space.

• To check any previous root canal treatment

• To check presence of any intraradicular pins or posts

• To see any resorption present in the tooth

• To chech any any calcification in the pulp space

• To see root end proximal structures

• Help in determining the working length ,length of master gutta percha and quality of obturation

• They help in knowing the level of instrumental errors like perforation ,ledging, and instrument separation .

• Also used to analyse post treatment periapical status.

WORKING RADIOGRAPHS

• The rasdiographs exposed during the treatment phase are known as working radiographs.

• 1.WORKING LENGTH DETERMINATION : In this ,radiograph establishes the distance from the reference point to apex at which canal is to be prepared and obturated .by using special cone angulations ,some superimposed structures can be moved to give clear image of the apex.

• 2. MASTER CONE RADIOGRAPHS: taken in the same way as the working length radiograph .master cone radiograph is used to evaluate the length and fit of master gutta percha cone.

• 3. OBTURATION : radiographs help to know the length ,density ,configuration and the quality of obturation .

DIGITAL RADIOGRAPHY

• Digital radiography is a form of X-ray imaging, where digital X-ray sensors are used instead of traditional photographic film. Advantages include time efficiency through bypassing chemical processing and the ability to digitally transfer and enhance images. Also less radiation can be used to produce an image of similar contrast to conventional radiography.

• Instead of X-ray film, digital radiography uses a digital image capture device. This gives advantages of immediate image preview and availability; elimination of costly film processing steps; a wider dynamic range, which makes it more forgiving for over- and under-exposure; as well as the ability to apply special image processing techniques that enhance overall display of the image

METHODS OF DIGITAL DENTAL RADIOGRAPHY

• 1. one uses charged couple devices

• 2. other uses photo stimulable phosphor imaging plates

• Digital imaging systems require :

1.electronic sensor or detector

2. an analog to digital convertor

3. a computer

4. a monitor

The most common sensor is the CCD ,the other being phosphor images

• When a conventional x ray unit is used to project the x ray beam on to the sensor ,an electric charge is created ,an analog output signal is generated and the digital converter converts the analog output signal from CCD to a numeric representation that is recognizable by the computer

• The radiographic image then appears on the monitor and can be manipulated electronically to alter contrast ,resolution , orientation ,and even size.

RVG

• CONSIST OF THREE MAJOR PARTS

• 1. THE RADIO PART CONSIST OF a conventional x ray unit , aprecise timer for short exposure times and a tiny sensor to record images .

The sensor has a small receptor screen which transmits information via fiber optic bundle to miniature CCD.

The sensor is protected from x ray degradation by a fiber optic shield and it can be cold sterilized.

2. VISIO PORTION consist a video monitor and display processing units .this recievs tye signal and stores incoming signal.

It can also display multiple images simultaneously .

ADVANTAGES

• Low radiation dose

• Diagnostic capability is increased

• Image distoprtion from bent radiographic film is eliminated

• Contrast and resolution can be altered

• Images are displayed instantly

• No dark room

• Reduction in time consumption

• Transfer of images between two different computers .

• Infection control and toxic waste disposal problems associated with radiology are eliminated

DISADVANTAGES

• Expensive

• Large disc space required to store images

• Bulky sensor with cable attachments ,which can make placement in mouth difficult

• Soft tissue imaging is not that appreciable

PHOSPHOR IMAGING SYSTEM : Imaging using a photostimuable phosphor can also be called as an indirect digital imaging technique .the image is captured on a phosphor plate as analogue information and is converted into a digital format when the plate is processed.