Lecture 2 2021

Subject: Endodontics Diagnosis: symptoms and treatment planning
Diagnosis is the science of recognizing disease by means of signs, symptoms and tests.
Symptoms: it is phenomena or signs of a departure from the normal and indicative of illness
I. Subjective Symptoms: Symptoms which are experienced and reported by the patients to the clinician.
II. Objective Symptoms: Symptoms which are ascertained by the clinician through various tests.
DIAGNOSIS STEP BY STEP
1. Medical History should include:

✓
present and past serious systemic illnesses, injuries, and surgery,
✓
a record of sensitivities or reactions to any drug or antibiotic (allergies: local anesthesia, antibiotics:
penicillin),
✓
the presence of cardiovascular disease (especially valvular disease with a history of rheumatic fever),
cardiac pacemaker
✓
blood pressure,
✓
hormonal disease (diabetes, hyperthyroidism)
✓
pregnancy
Knowledge of these medical factors might modify subsequent local treatment e.g.: use local anesthetic without
vasoconstrictors
The prevention of bacterial endocarditis [based on ESC Guidelines for the management of infective
endocarditis (2015)]
2. Chief complaint
The most common chief complaint in endodontics is pain.
Ask questions about pain
• Pain localization.
• Spontaneous/ provoked (cold, hot, sweet).
• The position of body, radiation of the pain
• Duration of pain (second, minutes, hour).
• Character of pain (intensity of pain): continuous, acute, dull, pulsating.
• History of pain: for the first time, former.

RADIATION OF THE PAIN- indicates irreversible pulpitis
Radiation of pain is always one-sided

Patient can localize the side (right/left) of radiation /can’t localize from which arch(mandible/maxilla)pain
comes
Pathological process:
In maxilla: radiation to the eye and temple
In mandible: radiation to ear, neck and occiput
Differentiation:
Pain radiating to the jaw are characteristic symptom of coronary artery disease
Sinusitis- radiating pain- upper molars and premolars (by tilting the head)
3. Clinical examination
Visual & tactile inspection:
Face symmetry
Sinus tracts
Lymph nodes
Trigeminal nerve
The examination of the teeth & the periodontium should always be done under:
1. dry conditions,
2. having optimum light and
3. most importantly using all possible barriers such as gloves, face mask and protective eye wear.
4. Diagnostic tests (pulp tests)
Electric pulp test
Thermal tests:
cold – ethyl chloride or ice
hot – gutta-percha heated

LDF
Percussion
Palpation
Mobility
Periodontal evaluation
Radiograph CONTROL TEETH

When using any test, it is important to include control (comparison) teeth of a similar type to the suspect
tooth or teeth.
Tests on these teeth educate the patient on what response to expect and provide a “calibrated”
baseline for the responses to tests on suspected teeth.
The patient should not be told whether the tooth being tested is a control or a suspect tooth.
The first application of the test is the most significant.

electric pulp test
thermal test (cold response)
LDF (Laser Doppler flowmetry)

• Not invasive
• Determine the absence or presence of blood circulation in the pulp
• Laser He-Ne, the result in the form of a graph
• The most objective method of assessing its vitality
• It is useful method in case of tooth trauma (pulp shock)
• The disadvantages: time consumption and high cost of the device
Additional tests: Gutta-percha point tracing with radiograph
Technique: Place a gutta percha point through the fistulous tract and take a radiograph.
Purpose: Can localize the endodontic lesion to the specific tooth.

CLASSIFICATION OF PULPAL DISEASES:
I. Normal pulp
II. Reversible pulpitis
III. Irreversible pulpitis

IV. Pulpal necrosis
I.Normal pulp
A tooth with a normal pulp is clinically symptom free and responds normally to vitality tests. Such a tooth does not
reveal any radiographic signs of pathosis.
II. Reversible pulpitis
Symptoms:
Reversible pulpitis is usually asymptomatic.
Application of stimuli, such as cold or hot liquids or air, may

produce sharp, transient pain. Removal of these stimuli, which do
not normally produce pain or discomfort, results in immediate
relief.
Cold and hot stimuli produce different pain responses in normal pulp. When heat is applied to teeth with
uninflamed pulp, the initial response is delayed; the intensity of pain increases as the temperature rises.
In contrast, pain in response to cold in normal pulp is immediate; the intensity tends to decrease if the
cold stimulus is maintained.
Treatment: The removal of irritants and sealing and insulating the exposed dentin or vital pulp usually result
in diminished symptoms and reversal of the inflammatory process in the pulp tissue.
Treatment:
· Carious lesions/ non carious lesions without pulp exposure- restorations or indirect capping (calcium
hydroxide, Biodentine)
· With pulp exposure- direct capping (eg MTA, Biodentine)
· Deep cavity with demineralized dentin left: step-wise excavation technique: incremetnal removal of caries over
a period of time to allow pulpal healing and to minimize exposure
· In each cases: severity of symptoms (reversible-->irreversible): pulpectomy
PULPECTOMY
In case of carious pulp exposure positive results of treatment with direct capping materials were observed in 30-
40% of cases, so in this situation in adult teeth better solution is pulpectomy.
The assessment criterion of changes pulpitis reversible into irreversible is decreased response to cold
while increased response to heat.
III. Irreversible pulpitis- treatment: pulpectomy

(anesthesia) Irreversible pulpitis can be symptomatic or
asymptomatic Symptomatic: spontaneous pain (with no external
stimuli).
Application of external stimuli, such as cold or heat, may result in prolonged pain.
If inflammation is confined to the pulp and has not extended periapically, teeth respond within normal limits
to palpation and percussion. The extension of inflammation to the PDL causes percussion sensitivity.
Hyperplastic pulpitis is usually asymptomatic
PULP POLYP
· pulp polyp is characteristic for irreversible pulpitis
· young people
· it consists of granulation tissue with big number of young vessels (massive bleeding after irritancy)
· painless during probing
· most commonly its surface covers the transplanted epithelium of the oral mucosa
· pulp polyp should be differentiated from gingival hyperplasia (the polyp can be surrounded by dental probe)
IV. Pulpal necrosis
Pulpal necrosis is usually asymptomatic but may be associated with episodes of spontaneous pain and discomfort or
pain (from the periradicular tissues) on pressuretive findings indicating death of the dental pulp.
The pulp of a tooth with necrotic pulp should be nonresponsive to vitality testing.
However, various degrees of inflammatory response are possible, ranging from reversible pulpitis to necrosis in
teeth with multiple canals, and this may occasionally cause confusion during testing for responsiveness (partial
necrosis)
Because of the spread of inflammatory reactions to periradicular tissues, teeth with necrotic pulps are often
sensitive to percussion.
Sensitivity to palpation is an additional indication of periradicular involvement.
ANTISPETIC ROOT CANAL TREATMENT

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Subject: Endodontics Diagnosis: symptoms and treatment planning

DIAGNOSIS STEP BY STEP

1. Medical History should include:

The most common chief complaint in endodontics is pain.

Ask questions about pain

• Spontaneous/ provoked (cold, hot, sweet).

• The position of body, radiation of the pain

• Duration of pain (second, minutes, hour).

• Character of pain (intensity of pain): continuous, acute, dull, pulsating.

• History of pain: for the first time, former.

Radiation of pain is always one-sided

Visual & tactile inspection:

2. having optimum light and

4. Diagnostic tests (pulp tests)

Electric pulp test

cold – ethyl chloride or ice

hot – gutta-percha heated

Radiograph CONTROL TEETH

The first application of the test is the most significant.

thermal test (cold response)

LDF (Laser Doppler flowmetry)

Additional tests: Gutta-percha point tracing with radiograph

Purpose: Can localize the endodontic lesion to the specific tooth.

II. Reversible pulpitis

III. Irreversible pulpitis

Reversible pulpitis is usually asymptomatic.

Application of stimuli, such as cold or hot liquids or air, may

· With pulp exposure- direct capping (eg MTA, Biodentine)

· In each cases: severity of symptoms (reversible-->irreversible): pulpectomy

III. Irreversible pulpitis- treatment: pulpectomy

Hyperplastic pulpitis is usually asymptomatic

· pulp polyp is characteristic for irreversible pulpitis

· painless during probing

IV. Pulpal necrosis

Sensitivity to palpation is an additional indication of periradicular involvement.

ANTISPETIC ROOT CANAL TREATMENT

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