1

DiagnosisPulp Pathosis

Process of making a diagnosis5 stages

1. Patient says why they have presented

2. Clinician probes with ??? – history of problem – symptoms related to current condition

3. Clinician performs OBJECTIVE tests4. Correlation of Objective and Subjective

data5. Definitive diagnosis

Adopt a systematic approach

Carefully engineered ????Elicit critical and pertinent dataListen carefully – picture will emerge to give inkling of the cause of the patients present complaint

To put it simply!QuestionListenTestInterpretAnswer

A proper approach to information gathering

Differential diagnosisProvisional diagnosisDefinitive diagnosis

Patients reason for seeking treatment

Often more important than tests performedDentist may find pathosisPotential to cause current complaintNot the pathological condition motivating the to patient present

2

Document chief complaint

Make a record of the patients own wordsDetail the patients description of the symptoms

Medical History!!Taken and reviewed with patient –patient to sign the historyThis will highlight the fact that this necessary step has been undertakenReview the history if patient not seen for more than 1 year

Current health conditionsDiseases and disordersMedications

Mediate the proposed treatmentMedical conditions which present oral symptoms and signsConditions which mimic dental pathosis

Examples:1. Maxillary sinusitis

Can mimic tooth ache in maxillary posterior teeth

2. Tumour of Central Nervous System, pressure on the Trigeminal Nucleus, pain in the oro-facial area

3. Myo-fascial pain Trigger points) small foci of hyper-excitable muscle tissuediffuse, dull,constant acheMistakenly attributed to tooth or teeth

4. Trigeminal NeuralgiaIntense, sharp, shooting pain, uni-lateralTrigger zonePain subsides within few mins.Response is not proportional to the intensity of the stimulus

See sample history sheets

“Pathways of The Pulp”Fig. 1-1Fig. 1-3

3

Recording the results of Tests

Pre-printed forms may be usefulSee “Pathways of The Pulp”

Fig. 1-3

History of the present dental complaint

Recent dental treatment What treatmentWhich tooth/teeth

Past dental treatmentHistory of present dental problem

When startedHow long present

Clinician’s Questioning

Once the patient has given their perception of the problemThis questioning should direct the interchange

Questions to Ask

?????????????

?????????????

LocalizationPut finger on or tap offending toothVery helpful

Can narrow the searchSymptoms may not be well localized

This presents more of a challenge

CommencementWhen did symptoms first occurPatient may remember an initiating eventE.g. recent dental treatment, trauma biting a hard object)

4

IntensityAsk patients to rate pain on a scale of 1 –10 with 10 being most severeUncomfortable sensation to cold or an annoying pain when chewing may rate as 3 – 4Unable to sleep with constant throbbing pain may rate a 10

ProvocationWhat elicits the pain?

ColdHotChewing (upon application of pressure or release)Touching (tongue, finger, toothbrush)Spontaneously

Relieved byColdNon-prescription analgesics

e.g. Panadol, Nurofen, AspirinOf particular interest are the anti-inflammatory pain medications

Duration – Is it?Relieved immediately –removal of stimulusLasting minutes or hoursIntermittent – spontaneous pain that will continue for hours but remit for variable periods and commence again unstimulated

Extraoral Examination

1. VisualFacial asymmetryLoss of definition of philtrum of upper lip or naso-labial foldSwelling – head, face, neckRedness

2. Palpation – Facial swellingDiffuseFirmFluctuantLocalized

Lymph nodesCervical, Sub-mandibularUni-lateral, Bi-lateral (medical condition?)

5

Facial swelling

Diffuse facial swelling

Localized facial swelling

Examples:Uni-lateral facial swelling, firm tender lymph nodesLikely infection

Localized infection has spread into surrounding tissues – now a systemic problemA diffuse facial swelling is generally of endo. origin. Rare with Perio. abscess

Loss of definition of philtrum of upper lip

Incisor endo. involvementLoss of definition of naso-labial fold

Canine involvementFluctuant swelling anterior palate

Upper lateral incisor or first pre-molar

Fluctuant swelling posterior palatePalatal roots upper molars

Intra-oral Examination1. Swelling

VisualizedPalpated

Diffuse, localized, firm, fluctuant

May be present in:Attached gingivaAlveolar mucosaMuco-buccal foldSub-lingual

Intra-oral swellingLocalized intra-oral swelling, upper buccal sulcus

Fluctuant swelling, anterior palate

2. Erythema3. Sinus formation

Can occur through:Attached gingivaMucosaFurcationPerio. ligament (gingival crevice)

6

Sinus TractsDrainage of inflammatory exudate from endo. infectionExits via StomaStoma may be extra-oral or intra-oralSinus tract may be lined by epithelium (not often) generally lined by granulation tissue

Intra-oral sinus

Attached gingiva

Resolution of sinus tracts

This will generally occur with appropriate and adequate endo. treatmentFailure to heal

Further investigationOther aetiological factors?Misdiagnosis?

Examples:Swelling in the muco-buccal fold

Upper molar teeth with buccal root apices inferior to the attachment of muscle in that regionLower molar teeth – buccal root apices superior to the muscle attachment

Infections associated with lower molars and pre-molars

Root apices above the level of mylo-hyoidExiting to lingualTongue elevated and swelling bi-lateral (no midline division of sub-lingual space)

Post. Max. and Mand. Teeth –infection can extend into tonsilar & para-pharyngeal areas

Potentially life-threatening

Mandibular incisors may involve the sub-mental and sub-mandibular spaces

Infection exits above mylo-hyoid attachment (sub-mental space)Infection exits inferior to mylo-hyoid (sub-mandibular space)

7

Extra-oral sinus stoma

Involvement of sub-mental region

Other intra-oral exams

1. Palpation - Alveolar hard tissues

Swelling of soft tissues overlying the bony processesExpansion of the buccal and lingual cortical plates (unlikely to be of endodontic origin)Patient sensitivity during this part of the exam

2. PercussionPatient c/o sensitivity or pain on masticationSuch a sign may be elicited by percussion

A measure of inflammation of the apical perio. ligament

Inflammation of the Periodontal Ligament

Possible causes:Physical traumaOcclusal traumaPerio diseaseAn extension of endodontic inflammation/infection to involve the apical periodontium

ProprioceptionProprioceptors provide the sensory input derived from mastication, percussion and other forms of pressure on a toothThere are few, if any, in the pulp

Difficult to localize pain in the early stages of pulp pathosis?

Prevalent in the ligamentWith peri-apical ligament involvementTooth more identifiable by percussion

Diagnostic Tests

8

Three primary purposes of tests

1. Reproduce symptoms2. Localize synptoms3. Assess severity

Psycho-social issuesExaggeration/understatement

When performing tests

Inform the patientReduces anxietyEnhancnes the diagnostic quality of the response

Conducting testsTest a contra-lateral tooth firstTest adjacent teeth next (that are more likely to give a normal response)Test the suspect tooth lastAsk patient to compare the response from suspect tooth to that from normal toothAsk if the response is painfulAsk how long the pain lasts

Technique for percussionTest first by tapping with gloved finger nailIf no discernable result, use mirror handle very lightlyOcclusally first

No response then test buccally and lingually

Positive response then repeat to confirm

Percussion Test MobilityDegrees of mobility

1° - greater than normal2° - less than 1mm3° - greater than 1mm with or without vertical mobility

Not a test of vitalityIndicator of compromised periodontal attachment apparatus

9

Mobility TestTwo instrument handles

Differential diagnosis –Mobility

Acute physical traumaOcclusal trauma – Bruxism or other para-functional habitsAdvanced periodontal diseaseRoot fractureRapid Orthodontic movementExtension of pulp pathosis i.e. acutely infected, non-vital teeth (acute abscess) –often mobile. Endo. treatment will reverse this situation

Perio examinationHow to differentiate perio. condition from a bony defect of endodontic originEndo. defects

Isolated, narrow opening, vertical defect. (Can be associated with a vertical crack)

Endo lesions may exhibit furcation bone lossFurcation defects - perio, endo, or combined

Thermal Pulp tests

If patient c/o sens. to cold then test with coldRecord

No responseNormal (WNL)Intensified (Moderate , Extreme)Lingering

Cold Test Method1,1-1,2 Tetra-fluoro Ethane Spray

Largish cotton pellet (make your own)Apply to mid-facial of teeth

10

Isolate and dry teethAs for percussion inform patientTest contra-lateral teethTest adjacent teethTest suspect tooth amongst teeth expected to give a normal responseInstruct patient not to try to figure out which

tooth you are testing rather to tell you “ what they feel”

Offer three options1. Cold2. Nothing3. Sensitivity or pain

Heat Test MethodPatient c/o sensitivity to hot food

test with both hot and cold

Isolate and dry teethLubricate teeth surfaces with petroleum jelleyUse White gutta percha stick and heat in flameApply to mid-facial area of teethAdopt the same procedures as for other tests using ‘control’ teeth

Heat Test

Spontaneous painA tooth that is responsive to hot is often responsible for episodes of spontaneous or continuous painOften relieved by cold stimulus e.g. cold liquids or ice pack

Pain relieved by cold

11

Electric Pulp TestsCold and electric test provide a fairly reliable indicator of vitalityBUT – A molar with only one vital root will sometimes give + response to cold which may be a heightened responseElectric test only gives indication of presence of any viable nerve tissue

Most accurate – NO RESPONSE to any amount of current – necrotic pulp

Electric pulp test unit

Probe

Patient completes circuit by touching metal probe handle

MethodIsolate, dry teethTest contra-lateral tooth to obtain base-line level of expected response (number on the dial of the tester unit)This will familiarise patient with the sensationTest suspect tooth twiceUse toothpaste as electrolyte to conduct current to toothApply probe to incisal 1/3 or facial aspect of post. teeth

Application of the probeTooth paste as electrolyte

If little exposed tooth

Crown and bridge work then look for any exposed toothUse probe/explorer and tooth paste and touch tester probe to the explorer

Cracked Tooth

Patient will often complain of pain on chewingThe diagnostic feature of this pain is that it is more noticeable when the pressure is releasedSpecially designed crack testers are available – “Tooth Sleuth”

12

Tooth Sleuth

Place on cusp tips

Pressure applied by opposing teeth

Individual cusps can be tested

Transillumination

Prepared by Lea FosterReferences

Pathways of the Pulp 9th Ed. Cohen, HargreavesEndodontic Therapy 6th Ed. WeinePrinciples and Practice of Endodontics Walton, TorebinejadHarty’s Endodontics in Clinical Practice Pitt FordColour Atlas of Endodontics Willaim T Johnson