1、牙體牙髓病診療學(xué)DIAGNOSIS 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 doubt. In those instances, it is best to postpone init

2、iating 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 , experience and expertise of the practitionerTo determin

3、e if it is necessary to consult or refer to other health professionalsDIAGNOSTIC TESTSThermal testElectric Pulp TestSinus Tract TracingRadiographsSelective anesthesiaPercussionPalpationPeriodontal probingSYSTEM OF DIAGNOSISRadiographic examinationperiapical changesperiodontaladjacent teethCariesDete

4、rmine pathosis and potential etiology REVIEW ONE STRUCTURE AT A TIMEDIAGNOSISRADIOGRAPHIC 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 regardless of angleDIAGNOSIS

5、 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 detected radiographically.

6、 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 landmark or other type of

7、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 TESTING Does not measure degree of he

8、alth or disease in pulp Yes or No response Results must be compared to other teethFalse positive-Large metal restoration, wet tooth, touching gingivaFalse Negative-Dead battery, no lip clip, lip dry, poor contact with toothPULPAL “A” fibers respond to stimulusMany variables can affect response with

9、EPT :enamel thickness, position of probe, calcification, patient anxiety, tooth with open apexPULP 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 cont

10、ra-lateral teethDont forget to investigate the opposing arch.PERIODONTAL ASSESSMENTPERIODONTAL PROBINGDIAGNOSISPULPALNormalReversible pulpitisIrreversible pulpitisNecroticPrevious Root canal therapy (previously treated)Previously intiated root canal therapyPERIAPICALNormal Periapical tissuesSymptoma

11、tic Apical periodontitisAsymptomatic apical periodontitisAcute apical abscessChronic apical abscessDefining 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 t

12、hat intracanal medicaments. Previously Initiated Therapy A clinical diagnostic category indicating 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 clinic

13、al symptoms including painful response to biting and percussion. It may or may not be associated with 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

14、clinical symptoms.Chronic apical abscess: Hallmark sinus tractSINUS TRACT TRACING Trace with Gutta percha point. If Endo lesion, it should lead to apex of involved tooth. Tract may emanate from a tooth which is one or two teeth away from tract.(#35 GP commonly used) #20 PULPAL: Necrotic PERIAPICAL:

15、Asymptomatic 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 # 26RESORPTIONINTERNA

16、L / EXTERNAL RESORPTIONRadiographic examination essential clinical element in diagnosis of resorptive lesionsRESORPTION : Pathologic process that results in the loss of substance from the root.External Root ResorptionInitiated in the PDL and affects the external or lateral surface of the root.Intern

17、al Root Resorption , Bell 1830Initiated within the radicular space. INTERNAL 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 stop

18、ping resorptionRADIOGRAPHIC INTERPRETATIONINTERNAL RESORPTIONINTERNAL RESORPTION #30 CALCIFIC METAMORPHOSISCondition follows trauma, particularly luxation Clinically, yellow discoloration of the clinical crown Extensive, progressive calcification which radiographically obliterates the pulp space Cha

19、racterized by deposition of hard tissue within the root canal space Commonly seen in the dental pulp after traumatic injury and is recognized as early as 3 months after injury, in most case not detected for about 1 year CALCIFIC METAMORPHOSIS DIAGNOSISIf inconclusive or contradictory findingsReferIt

20、s OK to say “I cant tell exactly where the problem is at this point. Lets put you on this medication for pain and let me see you again in 24-48 hours. Symptoms will often localize and we can accurately pinpoint the correct tooth or problem.”O(jiān)ften one or two days will make a difficult diagnosis an ea

21、sier one.DIAGNOSIS AFFECTS THE TREATMENT PLAN CLINICAL DATA SHEETForm that helps in facilitating complete and accurate 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

22、to differentiate a normal from an abnormal response to these pulp tests.Normal Response to Pulp TestingBaseline or 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

23、An abnormal response would include :A lack of response to stimulus (means necrotic)Lingering or intensification of 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 pul

24、pitis)Most common Primary Pulp test Performed is the Cold test To be most reliable, cold testing should be used in 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.He

25、at testing is performed by applying heated gutta percha or compound stick to the buccal surface of the teeth.Important : 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

26、adhering to the dry tooth surface.COLD TESTINGCOLD TESTINGCotton tip applicator or Cotton Pellet ? Jones, Rivera, and Walton, J Endo, 2002 Cotton tip applicator relatively ineffective Use Cotton pellet !Cotton pellet in place with the cotton pliersCotton tip applicatorPROPER TECHNIQUE FOR PULP TESTI

27、NG 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 large # 2 cotton pellet. VIDEO ON PULP TESTING TO FOLLOW ELECTRIC PULP TESTINGTh

28、e 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 fibers are present in the pulp and are capable of responding.TECHNIQUE: Imp StepsPr

29、oper 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 base line response.The suspected tooth should be tested at least twice to confirm t

30、he 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 pellet ?Cold Test with Endo Ice and Cotton Pellet Always Use a Cotton pellet for test

31、ing through a Crown or Bridge !Endodontic Treatment PlanningPulpal and Periapical DiagnosesDetermine the PrognosisDATA COLLECTIONChief ComplaintMedical and Dental HistoryClinical ExamExtra-oral: Fever, lymphadenopathyIntra-oral:Percussion, palpation, probing, mobilityCold test and EPTPROBLEM LISTDen

32、tal Caries Periradicular lesionsSwelling Microleakage (long-standing temporization)Sinus tracts, discolorationTrauma, Cracks or fractures Attrition, abrasion, erosionNon-healing of previous endodontic treatmentCongenital 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 lengthRoot canal prepar