Endodontic Assessments in a Differential Diagnosis

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Endodontic Assessmentsin a Differential Diagnosis

• The Endodontic-Restorative Continuum

Alan H. Gluskin DDS Professor and
Chair Department of Endodontics
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The Role of Endodontic Vitality Testingin
aDifferential Diagnosis
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Endodontic Differential Diagnosis
Medical / Dental
Extraoral Examination
Intraoral Examination
Tactile Exam
Radiographs
Vitality Tests
Definitive Diagnosis
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Extraoral Visual Examinations
Facial Asymmetry ? Yes / No
Aggressive Swelling ? Yes / No
Facial Injuries ? Yes / No
Purulent Drainage ? Yes / No
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Intraoral Visual Examination
Palpation
Probings
Percussion
Mobility
Radiographs
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Palpation / Digital Examination
Palpation Examination
Light Digital Pressure
Soft Tissues
Location
Pain Intensity
No Pain, Tender, Acute Pain
Indurated, Swollen Fluctuant
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Intraoral Visual Examination
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Endodontic Assessmentsin a Differential Diagnosis

• The Endodontic-Restorative Continuum

Alan H. Gluskin DDS Professor and
Chair Department of Endodontics
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Vitality Assessment Tools
Tentative Diagnosis
Thermal Cold Heat
Vital Test Cavity
Electric Pulp Tester
Selective Anesthesia
Tooth Slooth
Fiber Optic Light
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Establish A Point of Reference
Challenge Adjacent/ Contralateral Tooth
Challenge Opposing Tooth or Arch
Challenge Quadrant
Challenge Tooth in Question
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Vitality Assessment Tools
Radiographs
Thermal Cold Heat
Vital Test Cavity
Electric Pulp Tester
Selective Anesthesia
Tooth Slooth
Fiber Optic Light
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Tooth Responses
Responses From Tooth
Hypo Responsive
W.N.L.
Hyper Responsive
(-)
(-) / ()
( ) , ( )
Momentary
Lingers
Spontaneous
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Endodontic Differential Diagnosis
Medical / Dental
Extraoral Examination
Intraoral Examination
Tactile Exam
Radiographs
Vitality Tests
Definitive Diagnosis
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Dental History - The Science

• Recognize
• Understanding
• Interpreting

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Dental History - The Art

• Asking the RIGHT questions
• ACTIVE listening

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Dental Emergencies
Non-Pulpal Involvement
Toothache
Tooth Trauma
Tooth Knocked Out
Loose Tooth
Fractured Tooth
Chipped Tooth
Concussion
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Diagnosing Oro-facial Pain

• Dental
• Non-Dental

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Interpreting the Language of Pain
Subjective Coloring
Chronic
Acute
Low Grade Pain
Hx of Pain
Intense
Sharp
Spon-taneous
Deep, Gnawing
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Understanding the Language of Pain
Signs
Symptoms

Dental
Non-Dental
Dental
Non-Dental
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Inflammation

• Cellular
• Neurologic
• Vascular
• Humoral

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Language of Pulp Pain
Dental Pulp
Pulpal Inflammation
Asymptomatic
Symptomatic
Acute
Chronic
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Physiology of Pulpal Pain
Human Dental Pulp
Afferent Impulses
A-Delta Fibers
C-Fibers
Pain
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Physiology of Pulpal Pain

• A-delta Fibers
• Located in Pulp-Dentin Interface
• Myelinated
• Large Diameter

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A-delta Fibers Cold / HeatThermoreceptor for
Pain

• Quick
• Sharp
• Short

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Physiology of Pulpal Pain

• C- Fibers
• Located Centrally in the Pulp
• Unmyelinated
• Small Diameter

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C-Fibers - HeatThermoreceptor for Pain

• Steady
• Dull / Gnawing
• Prolonged / Spontaneous

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Acute Pulpal Origin
Acute Pulpal Pain
Temporary Pain
Abscess
Spontaneous
Diffuse
Localized
Short Duration
Constant
Pres-sure
Swell-ing
Fever
Cold
Heat
Increa-sing
Cold Hot
Throb-bing
Cold Relief
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Chronic Pulpal Origin
Chronic Pulpal Pain
Dull
Intermittent
Recurrent
Deep
Tolerable
Acute
Acute
Acute
Acute
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Endodontic Assessmentsin a Differential Diagnosis

• The Endodontic-Restorative Continuum

Alan H. Gluskin DDS Professor and
Chair Department of Endodontics
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Mobility - DepressibilityExamination

• Integrity
• of the
• Attachment Apparatus

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Tooth Mobility Evaluation
Mobility Examination
Light Lateral Pressures
Adjacent Teeth
Suspect Teeth
Class II
Class III
Class I
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Periodontal Ligament Reaction
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P.D.L. Reaction
Vital Pulp
Necrotic Pulp
Egressing Out
Healthy
Sick
Egressing Out
Trauma
Perio Disease
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Thermal Responses
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Cold Stimulus Challenge
Cold Test
Ethyl Chloride Refrigerants
Ice
Carbon Ice
Tooth
Hyper Response
W.N.L.
Hypo Response
Relief
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Cold Test
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Heat Challenge
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Heat Stimulus Challenge
Heat Test
Warm Gutta Percha
Hot Tap Water
Rubber Disc Friction
Tooth
Hyper Response
W.N.L.
No Response
Delayed Response
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Thermal Challenge
Pulpal Injury
Normal Pulp
Inflamed Pulp
Aged Pulp
Early
Late
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Neural Responses
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Electric Response Assessment
Electric Pulp Tester
Contralateral Tooth
Adjacent Tooth
Suspect Tooth
Hyper Response
W.N.L.
Hypo Response
No Response
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Neural Responses
Neuron Activity
Vital Pulp
Necrotic Pulp
Aged Tissues
Trauma to Pulp
Young Tissues
Total Necrosis
Partial Necrosis
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Sensory Pathways
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Sensory Pathways
Identifies Source of Tooth Pain
Identifies Referred Pain From Tooth
Identifies Non - Tooth Pain
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Anesthetic Diagnosis
Selective Anesthesia
Ligamental Injections
Local Anesthesia
Regional Blocks
Relieves Suspect Tooth
Reveals Referral Pain
Reveals Trigger Sites
Reveals Referral Pain
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Test Cavity Challenge
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Test Cavity Challenge
Test Cavity
No Anesthetic
Prepare Shallow Access
Penetrate Into Dentin / Chamber
No Response
Slight Response
Acute Response
Pulpal Necrosis
Degenerating Pulp
Vital Pulp
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Test Cavity
Extent of Pulp Vitality
Vital Pulp
Necrotic
100 Healthy
Degenerating
Endodontic Access
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Fractured Tooth Assessment
Tooth Slooth
Engage Cusp Tip
Bite Release
Sharp Pain
No Pain
Shallow Fx
Cuspal Fx
Vertical Fx
Horizontal Fx
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Occlusal Provocation
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Occlusal Provocation
Vital Tooth
Necrotic Tooth
Damage to Crown
Damage to Root
Damage to Root
Damage to Socket
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Crack Detection
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Tooth Slooth
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Checking for crack/fracture
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Crack MB cusp
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Deep isolated pocket
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Transillumination
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Transillumination
Fiber Optic Light Exam
Thru Cervical Line
Thru Line Angles
Thru Cusps Tips
Light Conductance
Through Through
Abrupt Stoppage
Surface Crazing
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Transillumination
Hard Tissue Integrity
Superficial Cracks
Deep Fractures
Moderate Crazing
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Acute Crack
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Misdiagnosis
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The Endodontic-Restorative Continuum
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Decision Making
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Decision Making
History Etiology Endo and / or Perio
Host Resistance Endo - Perio Patient Dental
I.Q. Operator Limitations
How Critical is Tooth? Cost
Effectiveness Treatment Alternatives Sequence
of Treatment Use of
Specialist
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Determination of Prognosis

• Periodontal Prognosis
• Endodontic Prognosis
• Restorative Prognosis

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Periodontal Prognosis

• Bone loss
• Pocketing
• Health of Periodontium

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Periodontal Concerns

• General periodontal status
• Isolated periodontal defect

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Endodontic Prognosis

• Vitality
• Periapical area
• Canals negotiable?
• Posts present?

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Endodontic Diagnosis Vital Tooth

• Reversible
• Irreversible

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Electric Pulp Tester
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Cold Test
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Cold Test
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Tooth Restorability

• Caries
• Chip in enamel
• Chip into dentin
• Cusp fracture
• Tooth fracture
• Root amputation

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Restorative Prognosis determined by
Structural Integrity
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Treatment Alternatives

• Restore as is...
• Restore as is... and extract
• Extract
• No further treatment
• Fixed partial denture
• Removable partial denture
• Implant

and hope
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Financial Considerations

• At UOP
• In Private Practice

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Ferrule Effect

• What is it?
• Facial/Lingual vs Mesial/Distal
• Anterior Tooth
• Posterior Tooth
• How wide / thick?

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How to achieve the ferrule

• Prep into sulcus
• Crown lengthening
• Extrusion

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Ferrule

• 1.5 -2 mm long
• Parallel walls
• Totally encircle tooth
• End on sound tooth surface
• Not invade attachment apparatus

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Core

• Replaces missing tooth structure
• Supports rehabilitation

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Core Materials

• Cast metal
• Amalgam
• Composite resin
• Glass Ionomer / Glass Ionomer Silver materials

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Fractured Cusp into Furcation
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Crown/restorative disassembly
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Tooth isolated for endodontics
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Resin syringe
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Build-up matrixed
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Crown lengthening
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Post-op crown lengthening
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Post-op crown lengthening
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Thank You