Examination and Diagnosis of Pulp, Root Canal, and Periapical/Periradicular Conditions
UNIVERSITY OF MOSULCOLLEGE OF DENTISTRY
By :Dr Ali Moayid
Lecturer Name: Introduction to dental anatomy
2020-2021
Department of
Conservative Dentistry
5th YEARs
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRYDepartment of:
HERE
The pulp, root canal, and periapical/periradicular tissues are all inter-related and the conditions within the pulp or root canal have a direct effect on the periapical and periradicular tissues.
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRY
Department of:
HERE
The first, and the most important, step in managing any condition is to determine what the condition is, that is, it must be diagnosed. In addition, the causes of the problem must be identified.
Once this information has been gathered, the appropriate options for managing the problem will become obvious. However, unfortunately, many clinicians do not take enough time to establish a meaningful or correct diagnosis and they often proceed immediately to providing some form of treatment.
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COLLEGE OF DENTISTRYIn most situations, the term “condition” is used rather than “disease” since not every state of these tissues is a disease process or an indication of pathosis of the tooth and surrounding tissues. The term “disease” will be used where there is clearly a disease process occurring.
In particular, the diagnosis will indicate the management options available for the condition as it can be considered that “Diagnosis Drives Dentistry.” The diagnosis will also determine the details of the treatment required.
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRYThe possible endodontic management options for teeth with pulp, root canal, and periapical/periradicular conditions usually include one or more of the following, depending on the diagnosis of the specific presenting problem:
• No treatment—but review and reassess.
• Restoration of the tooth (or replacement of the existing restoration).
• Conservative pulp treatment—such as indirect or direct pulp capping, partial pulpotomy, pulpotomy, or partial pulpectomy.
• Pulpectomy and root canal treatment.
• Root canal treatment of pulpless teeth.
• Root canal retreatment.
• Periapical surgery—or other surgical procedure(s).
• Systemic medications—such as nonsteroidal antiinflammatory drugs (NSAID’s), analgesics, antibiotics, and so forth.
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRYDiagnosis is the art and science of detecting and distinguishing deviations from health and the cause
The purpose of a diagnosis is to determine what problem the patient is having and why the patient is having that problem.
Ultimately, this will directly relate to what treatment, if any, will be necessary. No appropriate treatment recommendation can be made until all of the whys are answered
The data must be interpreted and processed to determine what information is significant, and what information might be questionable.
The facts need to be collected with an active dialogue between the clinician and the patient, with the clinician asking the right questions and carefully interpreting the answers.
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRY
Neither the art nor the science is effective alone. Establishing a differential diagnosis in endodontics requires a unique blend of knowledge, skills, and ability to interpret and interact with a patient in real time.
Questioning, listening, testing interpreting, and finally answering the ultimate question of why will lead to an accurate diagnosis and in turn result in a more successful treatment plan.
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COLLEGE OF DENTISTRYMedical History
The patient “of record” should be questioned at each treatment visit to determine whether there have been any changes in the patient’s medical history or medications
Baseline blood pressure and pulse should be recorded for the patient at each treatment visit. Elevation in blood pressure or a rapid pulse rate may indicate an anxious patient who may require a stress reduction protocol, or it may indicate that the patient has hypertension or other cardiovascular health problems.
The temperature of patients presenting with subjective fever or any signs or symptoms of a dental infection should be taken
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COLLEGE OF DENTISTRYThe clinician should evaluate a patient’s response to the health questionnaire from two perspectives:.
1. Those medical conditions and current medications that will necessitate altering the manner in which dental care will be provided
any drug allergies or interactions, allergies to dental products,
an artificial joint prosthesis,
organ transplants,
or is taking medications that may negatively interact with common local anesthetics, analgesics, sedatives, and antibiotics.
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COLLEGE OF DENTISTRY2. those medical conditions that may have oral manifestations or mimic dental pathosis
Many of the oral soft tissue changes that occur are more related to the medications used to treat the medical condition rather than to the condition itself. More common examples of medication side effects are stomatitis, xerostomia, petechiae, ecchymoses, lichenoid mucosal lesions, and bleeding of the oral soft tissues
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COLLEGE OF DENTISTRYWhen developing a dental diagnosis, a clinician must also be aware that some medical conditions can have clinical presentations that mimic oral pathologic lesions
For example,
tuberculosis involvement of the cervical and submandibular lymph nodes can lead to a misdiagnosis of lymph node enlargement secondary to an odontogenic infection.
Immunocompromised patients and patients with uncontrolled diabetes mellitus respond poorly to dental treatment and may exhibit recurring abscesses in the oral cavity that must be differentiated from abscesses of dental origin
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRYPatients with iron deficiency anemia, pernicious anemia, and leukemia frequently exhibit paresthesia of the oral soft tissues. This finding may complicate making a diagnosis when other dental pathosis is present in the same area of the oral cavity
Sickle cell anemia has the complicating factor of bone pain, which mimics odontogenic pain, and loss of trabecular bone pattern on radiographs, which can be confused with radiographic lesions of endodontic origin.
Multiple myeloma can result in unexplained mobility of teeth
.
Radiation therapy to the head and neck region can result in increased sensitivity of the teeth and osteoradionecrosis.
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COLLEGE OF DENTISTRYTrigeminal neuralgia, referred pain from cardiac angina and multiple sclerosis can also mimic dental pain
Acute maxillary sinusitis is a common condition that may create diagnostic confusion because it may mimic tooth pain in the maxillary posterior quadrantIn this situation the teeth in the quadrant may be extremely sensitive to cold and percussion, thus mimicking the signs and symptoms of pulpitis.
This is certainly not a complete list of all the medical entities that can mimic dental disease, but it should alert the clinician that a medical problem could confuse and complicate the diagnosis of dental pathosis
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COLLEGE OF DENTISTRYDental History
The chronology of events that lead up to the chief complaint is recorded as the dental history . This information will help guide the clinician as to which diagnostic tests are to be performed. The history should include any past and present symptoms, as well as any procedures or trauma that might have evoked the chief complaint
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COLLEGE OF DENTISTRYEXAMINATION AND TESTING
Extraoral Examination
Signs of physical limitations may be present, as well as signs of facial asymmetry that result from facial swelling
Visual and palpation examinations of the face and neck are warranted to determine whether swelling is present. Many times a facial swelling can be determined only by palpation when a unilateral “lump or bump” is present. The presence of bilateral swellings may be a normal finding for any given patient; however, it may also be a sign of a systemic disease or the consequence of a developmental event
Palpation of the cervical and submandibular lymph nodes If the nodes are found to be firm and tender along with facial swelling and an elevated temperature, there is a high probability that an infection is present
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRYSwellings of non-odontogenic origin must always be considered in the differential diagnosis, especially if an obvious dental pathosis is not found
Pulpal necrosis and periradicular disease associated with a maxillary canine associated with a canine space infection, but most extraoral swellings associated with the maxillary centrals express themselves as a swelling of the upper lip and base of the nose
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRY
If the buccal space becomes involved, the swelling will be extraoral in the area of the posterior cheek
These swellings are generally associated with infections originating from the buccal root apices of the maxillary premolar and molar teeth and the mandibular premolar and first molar teeth
why
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COLLEGE OF DENTISTRYThe mandibular second and third molars may also be involved, but infections associated with these two teeth are just as likely to exit to the lingual where other spaces
Extraoral swelling associated with mandibular incisors will generally exhibit itself in the submental or submandibular space
Infections associated with any mandibular teeth, which exit the alveolar bone on the lingual and are inferior to the mylohyoid muscle attachment, will be noted as swelling in the submandibular space
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COLLEGE OF DENTISTRYSinus tracts of odontogenic origin may also open through the skin of the face These openings in the skin will generally close once the offending tooth is treated and healing occurs
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COLLEGE OF DENTISTRYSwelling in the anterior part of the palate is most frequently associated with an infection present at the apex of the maxillary lateral incisor or the palatal root of the maxillary first premolar
A swelling in the posterior palate is most likely associated with the palatal root of one of the maxillary molars
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COLLEGE OF DENTISTRYIntraoral swelling present in the mucobuccal fold can result from an infection associated with the apex of the root of any maxillary tooth that exits the alveolar bone on the facial aspect and is inferior to the muscle attachment present in that area of the maxilla
The same is true with the mandibular teeth if the root apices are superior to the level of the muscle attachments and the infection exits the bone on the facial
Intraoral swelling can also occur in the sublingual space if the infection from the root apex spreads to the lingual and exits the alveolar bone superior to the attachment for the mylohyoid muscle. The tongue will be elevated and the swelling will be bilateral because the sublingual space is contiguous with no midline separation
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRYIf the infection exits the alveolar bone to the lingual with mandibular molars and is inferior to the attachment of the mylohyoid muscle, the swelling will be noted in the submandibular space
Severe infections involving the maxillary and mandibular molars can extend into the parapharyngeal space, resulting in intraoral swelling of the tonsillar and pharyngeal areas. This can be life threatening if the patient’s airway becomes obstructed
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COLLEGE OF DENTISTRYIntraoral Sinus Tracts
On occasion, a chronic endodontic infection will drain through an intraoral communication to the gingival surface and is known as a sinus tract . This pathway, which is sometimes lined with epithelium, extends directly from the source of the infection to a surface opening, or stoma, on the attached gingival surface.
As previously described, it can also extend extraorally. The term fistula is often inappropriately used to describe this type of drainage.
Tracing the sinus tract will provide objectivity in diagnosing the location of the problematic tooth. To trace the sinus tract, a size #25 or #30 gutta-percha cone is threaded into the opening of the sinus tract
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRYWhen a narrow defect is present, the differential diagnosis must include the opening of a periradicular endodontic lesion, a vertical root fracture, or the presence of a developmental groove on the root surface.
This type of sinus tract can be differentiated from a primary periodontal lesion because the latter generally presents as a pocket with a broad coronal opening and more generalized alveolar bone loss around the root. Other pulp testing methods may assist in verifying the source of infection
The stomata of intraoral sinus tracts may open in the alveolar mucosa, in the attached gingiva, or through the furcation or gingival crevice. They may exit through either the facial or the lingual tissues depending on the proximity of the root apices to the cortical bone. If the opening is in the gingival
crevice, it is normally present as a narrow defect in one or two isolated areas along the root surface.
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRYPalpation
A palpation test is performed by applying firm digital pressure to the mucosa covering the roots and apices. The index finger is used to press the mucosa against the underlying cortical bone. This will detect the presence of periradicular abnormalities or specific areas that produce painful response to digital pressure. A positive response to palpation may indicate an active periradicular inflammatory process. This test does not indicate, however, whether the inflammatory process is of endodontic or periodontal origin
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRYPercussion
Pain to percussion does not indicate that the tooth is vital or nonvital but is rather an indication of inflammation in the periodontal ligament (i.e., symptomatic apical periodontitis). This inflammation may be secondary to physical trauma, occlusal prematurities, periodontal disease, or the extension of pulpal disease into the periodontal ligament space
Before percussing any teeth, the clinician should tell the patient what will transpire during this test. Because the presence of acute symptoms may create anxiety and possibly alter the patient’s response, properly preparing the patient will lead to more accurate results. The contralateral tooth should first be tested as a control, as should several adjacent teeth that are certain to respond normally
UNIVERSITY OF MOSUL
COLLEGE OF DENTISTRY