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Pulpal and Periapical diagnosis (Dx of cracks/fractures (Mobility,…
Pulpal and Periapical diagnosis
Science of recognizing disease by its sign, symptoms and tests
Systematic approach
exams
Subjective
Pain
Severity
Duration
Location
Pain that cannot be localized may be of pulpal origin
Proprioceptors in PDL, but not in pulp
Eliciting stimuli
Ask about history
Based on CC
Objective
Extraoral
Intraoral
Soft tissue
Palpation
Palpate swellings to determine localized, diffused, firm or fluctuant
Exploration
Check for abnormalities in texture and colour
Document/biopsy/refer lesions, ulcerations
Retract tongue + cheek
Dry mucosa and gingiva (gauze, air)
Probing
a pocket of endodontic origin –> cracked tooth–> precipitous pocket
you will probe around a tooth and it will be normal, then suddenly, the probing depth will be really high in one location (2, 2, 2, 10**)
Sinogram
gutta percha is penetrated into a fistula + sinus tract and then radiographed
Swellings that drain are not painful but those that don't usually are
Hard tissue
STP + mobility
Tooth is pushed out of the socket a little bit due to periapical abcess –> pt may feel that one side is coming into contact before the other
Pts can pick up differences of a tenth of a mm
Percussion doesn't indicate pulpal status
º of response proportional to º of inflammation
May indicate root fracture
Technique:
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If tenderness or pain:
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mobility
could be from:
PD
Root fractures
Parafunctional habits
Ortho movement
Occlusal trauma
Acute/chronic physical trauma
Extension of pulpal infection
Radiographs
Dx aid
Look for: Coronal restorations, caries, PDL widening, Radicular RL, inadequate endodontic tx
Pulp Vitality Tests
Electric pulp testing (EPT)
Only denotes that some viable nerve fibres are present
Readings are relevant only if significantly different from controls
doesn't reflect histological health or disease of pulp
EPT is more accurate when no response is obtained
Technique:
Tooth to be evaluated has to be isolated + dried
Similar control tooth has to be tested
Pt removes fingers from probe when tingling/warming sensation is felt
Suspected tooth should be tested 2x
Tip of the probe has to be coated with water or petroleum based media (toothpaste)
Once probe contacts pt, pt touches probe to close the circuit
EPT readings are recorded
Responses:
Negative: pulp necrosis
Positive: Vital pulp, not reliable @ high intensity
False positive: metallic restorations
False negative:
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Special tests
Cavity test
Useful when suspected tooth is covered by a crown
Pt is not under LA
Used only when all other tests are inconclusive
Pain–> pulp is vital
No pain –> necrotic pulp
Selective anesthesia
Select maxillary arch first
Do intraligamentary LA on most posterior tooth
Pt cannot specify where pain is coming from
Move forward with LA one tooth @ a time until pain is eliminated
Laser Doppler Flowmetry
Thermal
Hot
Indicated when:
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Technique:
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Cold
Establish a method with pt to identify pain
Always try on contralateral tooth b/f suspected tooth
Explain procedure to pt
Record onset time of response and time pain lingered
Use Isolation
Compare baseline and suspected tooth
ENDO ICE
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Responses
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Occlusal analysis
Helps to determine:
Occlusal interference
TMJ disorders
Risk of trauma/fracture
Exploration
Discolouration
Drugs, systemic conditions, smoking, trauma, resorption
Wear facets
could be paraf(x) –> chips and glassy translucency in upper incisors
Transillumination for cracked teeth
Light transmitted from one side to the other –> shadows could be decay or due to crack
Analysis of the data
Get MHx and DHx
Formulate the appropriate Dx
Ascertain the CC
Dx of cracks/fractures
Mobility
Transillumination
RL (present or not)
Pain to percussion
Deep isolated pockets
Bite tests (with sleuth)