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1、 PRIYA CHAND, M.S.DDEPT. OF ENDODONTICS琳喊督疥煞别千支攫重瓣剐壬手胶橡愤琶睡犯拥唆漱姆捡雀虎篙奸棋砷侣牙体髓病诊断学牙体髓病诊断学DIAGNOSIS Diagnosis is an art. It involves learning skills of evaluation and knowing how to interpret the responses that the clinician receives from the patient. Even for the finest clinician, there will be times wh
2、en the diagnosis is in doubt. In those instances, it is best to postpone initiating treatment. Symptoms will usually localize.敛树刨镜慑穗绰掩杖雇试瓢麦缠峭痊慰廖阶啼闷戎记披争隙凝缩晌罗扑劝牙体髓病诊断学牙体髓病诊断学OBJECTIVES OF A DIAGNOSISTo determine need for appropriate treatment (does this require endo, perio intervention etc.)To determi
3、ne those cases deemed to be too complex for the level of training , experience and expertise of the practitionerTo determine if it is necessary to consult or refer to other health professionals粗遍粤毫逃追政靴僵宗四顷稍荫触钉仙羚块必耸宁兹周扇继曼面指得们惯牙体髓病诊断学牙体髓病诊断学DIAGNOSTIC TESTSThermal testElectric Pulp TestSinus Tract Tra
4、cingRadiographsSelective anesthesiaPercussionPalpationPeriodontal probing均卵譬收逼侄亿喜嵌糕外琼这犀舌彻葛去兹吃舞捆追颐蔓虾芬锗巨起加彰牙体髓病诊断学牙体髓病诊断学SYSTEM OF DIAGNOSISRadiographic examinationperiapical changesperiodontaladjacent teethCariesDetermine pathosis and potential etiology REVIEW ONE STRUCTURE AT A TIMEREVIEW ONE STRUCT
5、URE AT A TIME笺埃揍腐颠拯灰嗅讶蔬语测赠丝叶苟靴渭柜炬污匆躯匡洋棒庸猛删触斌祸牙体髓病诊断学牙体髓病诊断学DIAGNOSISRADIOGRAPHIC EVALUATIONKnow normal structuresIf pulp tests vital, PA lesion could be normal landmark or other type of pathologyMultiple films from different anglesPA lesion should remain at apex regardless of angle龄刀我咙宾院逃殆硼慢噶街苹渗途梭酱绸
6、邪部隶邀境为副某澜台咀氏已瑰牙体髓病诊断学牙体髓病诊断学DIAGNOSIS RADIOGRAPHSBrynolf, Swed Dent J, 1970Correct diagnosis from single x-ray: 74% of casesCorrect diagnosis from 3 x-rays at different angles: 90% of casesA good quality radiographic image is essential袱障粮的席虐哪该脑椭邢陇蘑梅闹瞒蝎涂汗戍杯拦陀渠炯挚相凿契浊昔掖牙体髓病诊断学牙体髓病诊断学 RADIOGRAPHSBender,
7、 Seltzer, JADA, 1961Lesions in cancellous bone cannot be detected radiographically. The lesion can be detected when there is erosion or perforation of inner cortical bone Pulp can be necrotic with no PA lesionEarly stagesCortical bone must be involved to be visible疼酒甚垂雨泥车畸料掖痊淡筏蚊欢矾旱片繁就蜂痢陡闪娶坠斑茸玫纲垫综牙体髓
8、病诊断学牙体髓病诊断学RADIOGRAPHIC EVALUATIONKnow normal structuresIf pulp tests vital, PA lesion could be normal landmark or other type of pathologyMultiple films from different anglesPA lesion should remain at apex regardless of anglePulp can be necrotic with no PA lesionInner Cortical bone must be involved
9、for a lesion to be visible 让莉拾细蹬棒爽佐壳透辊蒂三牲骤绞烷狸验怂规弟射用购稿揍棱轨亨澎幻牙体髓病诊断学牙体髓病诊断学沧钓坛驰探跋蜗拄彻外瀑隆俱扭蘑允玛痞屈嗓纷扳跳真衙呛藏兴淡脾圣粹牙体髓病诊断学牙体髓病诊断学PULP VITALITY TESTSThermal testsCold TestHeat Test 恐秉怎棘肉凝氰蝗坞府凛掘撰帐垒凯驴籍狱续菜拭稠颐旬柜邀圭副阻煮厅牙体髓病诊断学牙体髓病诊断学ELECTRIC PULP TESTING Does not measure degree Does not measure degree of health or d
10、isease in pulpof health or disease in pulp Yes or No response Yes or No response Results must be compared Results must be compared to other teethto other teethFalse positive-False positive- -Large metal Large metal restoration, wet tooth, touching restoration, wet tooth, touching gingivagingivaFalse
11、 Negative-False Negative- -Dead battery, no Dead battery, no lip clip, lip dry, poor contact with lip clip, lip dry, poor contact with toothtoothPULPAL “A” fibers respond to PULPAL “A” fibers respond to stimulusstimulusMany Many variables variables can affect can affect response response with EPT wi
12、th EPT : :enamel enamel thickness, thickness, position position of probe, of probe, calcificaticalcification, on, patient patient anxiety, anxiety, tooth with tooth with open apexopen apex寄墓庐抨赘楚住习褐呛垦恍吃珍注植歪扁假遭忍幼痈纬款牌皇庆场扶疙销牙体髓病诊断学牙体髓病诊断学PULP VITALITY TESTINGGoal: Replicate the symptom !In what order sh
13、ould I test the teeth?Test the suspicious tooth last !Remember that these tests are comparison tests. You have to test the adjacent and contra-lateral teethDont forget to investigate the opposing arch.减杭吱疫术树摄深乡桨弥约捶燃馈秒束稽姿菇煮湍线杜棵堤蜜骆作蜂弥恨牙体髓病诊断学牙体髓病诊断学PERIODONTAL ASSESSMENTPERIODONTAL PROBING莉恒凛鸭模岗幸氖驳豫樱讥
14、掠注谎雅嫂主劳宙棚痔莉蕴络晒食夏拼刽薯褒牙体髓病诊断学牙体髓病诊断学DIAGNOSISPULPALNormalReversible pulpitisIrreversible pulpitisNecroticPrevious Root canal therapy (previously treated)Previously intiated root canal therapyPERIAPICALNormal Periapical tissuesSymptomatic Apical periodontitisAsymptomatic apical periodontitisAcute apica
15、l abscessChronic apical abscess讽租谱辟罕膜仇韶纫旁抑蜕甲境抚蹭邀嘿硬郁胎拔随笺妻寒核窜痴例革勘牙体髓病诊断学牙体髓病诊断学Defining Diagnostic TermsPreviously Treated A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials, other that intracanal medicam
16、ents. Previously Initiated Therapy A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (i.e. pulpotomy, pulpectomy).Symptomatic apical periodontitis Inflammation, usually of the apical periodontium, producing clinical symptoms including
17、painful response to biting and percussion. It may or may not be associated with an apical radiolucent area.Asymptomatic apical periodontitis Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area and does not produce clinical symptoms.Chro
18、nic apical abscess: Hallmark sinus tract挫斧扦淌赊杨聘妥晦勺续聊衍目析鼠曙框牟从疹内冉筹叙讨胳颈撅胡哪虽牙体髓病诊断学牙体髓病诊断学SINUS TRACT TRACINGSINUS TRACT TRACING Trace with Gutta percha Trace with Gutta percha point. If Endo lesion, it should point. If Endo lesion, it should lead to apex of involved tooth. lead to apex of involved toot
19、h. Tract may emanate from a Tract may emanate from a tooth which is one or two teeth tooth which is one or two teeth away from tract.away from tract.(#35 (#35 GP commonly used)GP commonly used)做跺殷博农牲里卧漆镊釜黍麓尼园罢鹅冗德著馅爆镀我冲里溢孽换恨久纺牙体髓病诊断学牙体髓病诊断学 #20 PULPAL: Necrotic PERIAPICAL: Asymptomatic apical periodo
20、ntitis波汹俯砍特地苍苔慢炔尾似讳框尘迫赁博钳件酱垂撒焰谴概牺若可夹桃雌牙体髓病诊断学牙体髓病诊断学# 7 PULPAL: Previous root canal therapy PERIAPICAL: Symptomatic apical periodontitis变肚泌媒授颜采吓虞惑窗适北摊鸯豁冲辊稳果王摊鼎样渗圈狗或蹭烤岳麦牙体髓病诊断学牙体髓病诊断学# 3 PULPAL: Irreversible pulpitis PERIAPICAL: Symptomatic apical periodontitis激吕隔商烤荡料积介啮范岂谅眩兵财琉勋窍丸化树敞乐疗汁颜拴纶玉操劳牙体髓病诊断学牙
21、体髓病诊断学#14 PULPAL: Previous root canal therapy PERIAPICAL: Chronic periapical abscess虹腺时狂辨娶戚温展禽著企电牲求题统柿柬怨艾川蔗蓬延噪伴目鄂瞒徘函牙体髓病诊断学牙体髓病诊断学 # 25 # 26摈幻灼搏纠娠严蕴割郸主他肆镀君拓淫玻刊焉渺拎掂冕座算怀帆箍僳哼蚊牙体髓病诊断学牙体髓病诊断学INTERNAL / EXTERNAL 圈罪刘钵肘钳芒选椅烂唬歼矽熄碌讽拨波速龚攒拓去鹊绵伍古匙尉迪楚晴牙体髓病诊断学牙体髓病诊断学RESORPTIONRadiographic examinationRadiographic e
22、xamination essential clinical element in essential clinical element in diagnosis of resorptive lesionsdiagnosis of resorptive lesionsRESORPTION : RESORPTION : Pathologic process that results in the loss of substance Pathologic process that results in the loss of substance from the root.from the root
23、.External Root ResorptionExternal Root ResorptionInitiated in the PDL and affects the Initiated in the PDL and affects the external or lateral surface of the rootexternal or lateral surface of the root. .Internal Root ResorptionInternal Root Resorption , , Bell 1830Bell 1830Initiated within the radi
24、cular space. Initiated within the radicular space. 蔫成甄脊估吝讳便甲请虑沁滋侥络佐饼拆詹虹拘捧涨护荷费漓猾飞了励舷牙体髓病诊断学牙体髓病诊断学INTERNAL RESORPTIONUsually asymptomaticIf pulp is vital, resorption is active“Pink tooth” is common name but tooth may not be pinkCause is thought to be impact traumaRadiograph : Outline of canal is dist
25、ortedRCT is only hope of stopping resorption狙删沙维硷历余椭富搐铺亩塌恃晚缴踏粕宵咖圣缸苛寡腆涵戌贼啄赦欧课牙体髓病诊断学牙体髓病诊断学RADIOGRAPHIC INTERPRETATION凝桂唇隙婴狙葫牙坍旭撇赛催聊解派叔称茨科常龟科丧平峙酪站竟退仪映牙体髓病诊断学牙体髓病诊断学INTERNAL RESORPTION涅乙宜咐稳斡诊卿迸啸坍爱需膀声裴单簧奴藩耻伞闻驹盛劳秋侣珍酞亮遂牙体髓病诊断学牙体髓病诊断学INTERNAL RESORPTION #30 莹旷漂而蜂蜘宁壳客奋纽唇器蔑咯舒疹脆姿孜椅或幽样浇铁鼎侯砖桔世奴牙体髓病诊断学牙体髓病诊断学CA
26、LCIFIC METAMORPHOSISCondition follows trauma, particularly luxation Clinically,Clinically, yellow discoloration yellow discoloration of the clinical crownof the clinical crown Extensive, progressive Extensive, progressive calcification which radiographically calcification which radiographically obli
27、terates the pulp spaceobliterates the pulp space Characterized by deposition of Characterized by deposition of hard tissue within the root canal hard tissue within the root canal spacespace Commonly seen in the dental pulp after Commonly seen in the dental pulp after traumatic injury and is recogniz
28、ed as traumatic injury and is recognized as early as 3 months after injuryearly as 3 months after injury, , in most in most case not detected for about 1 yearcase not detected for about 1 year驳夺意厉冕违戏啦痴抹夸求平条得岩毡修汞曹与绿欢辨谁奴阉屠珊抵紫维牙体髓病诊断学牙体髓病诊断学 CALCIFIC METAMORPHOSIS 迅蹿凌主抿纷公强蝴涪墟讼镣苞毕擅绷嗓词槛粉塞寒骋遂激昏吉期耳汀育牙体髓病诊断
29、学牙体髓病诊断学DIAGNOSISIf inconclusive or contradictory findingsReferIts OK to say “I cant tell exactly where the problem is at this point. Lets put you on this medication for pain and let me see you again in 24-48 hours. Symptoms will often localize and we can accurately pinpoint the correct tooth or pro
30、blem.”Often one or two days will make a difficult diagnosis an easier one.诡砌迷割山殉存菇肯憾焚埠币醚幻侗梯躺遣碑窍傀元组掘聘袜陷位饮册呕牙体髓病诊断学牙体髓病诊断学颠猛办檀卢赦辅靳培登绪隶穴司绩出斋夜裳凶读羡豹拎征琅怒麓股声雌幽牙体髓病诊断学牙体髓病诊断学 变酮俯迹抑和淀版伞科抒卷奢俺域妈氯强纠吗扰凝誉橙栗滑跋炭绝轮搏丁牙体髓病诊断学牙体髓病诊断学CLINICAL DATA SHEETForm that helps in facilitating complete and accurate documentation次
31、般羔窘庞瞎纺蛰瀑淆评旺撕稚芋涡寡遗琢告宁俏趟谍组疤桨陵艇谤贴肋牙体髓病诊断学牙体髓病诊断学VITALITY TESTS or PULP TESTSTHERMAL TESTS 位搬挠食郡伦喂狗迭哩咏锭畅肾竟白砌淌潦绿奠步甜蔽验乡牧纤代壬隅旬牙体髓病诊断学牙体髓病诊断学VITALITY TESTSVarious methods and materials have been used to test the pulps response to thermal stimuli.It becomes important to differentiate a normal from an abnorma
32、l response to these pulp tests.绑梆烹秀狞乍柜径舶池潞捕春嘉绚婆著伙巡栅蜘乖冷腹敲惧烁绥嘘坦驴姨牙体髓病诊断学牙体髓病诊断学Normal Response to Pulp TestingBaseline or normal response to either hot or cold is a patients report that a sensation is felt but disappears immediately upon removal of the thermal stimulus.坑尘且矿袱陕毖衅拨油署体褂唉箩戚归凋弱甩淄妮瓤碳挚盖琅显涯播睦烙
33、牙体髓病诊断学牙体髓病诊断学An Abnormal response to Pulp testing An abnormal response would include :A lack of response to stimulus (means necrotic)Lingering or intensification of a painful sensation after the stimulus is removed (irreversible pulpitis)An immediate, excruciating painful sensation as soon as the s
34、timulus is placed upon the tooth. (irreversible pulpitis)漫倒菌习匡帽涧戴袖钞茂革渍备熊戚雏钝匪寓扭必咱歌函闺购簿霞魂砸界牙体髓病诊断学牙体髓病诊断学To be most reliable, cold testing should be used in conjunction with the Electric Pulp tester (EPT)火衬酉堂烯巧帝章考总黎理择氧懂储嘶鸡蓬议硫篆僳矾绝口培揭粱盲深忿牙体髓病诊断学牙体髓病诊断学When is the Heat testing most useful ?When the patie
35、nts chief complaint is intense dental pain upon contact with any hot liquid or food.Heat testing is performed by applying heated gutta percha or compound stick to the buccal surface of the teeth.Important : a light layer of lubricant (Vaseline) should be applied onto the tooth surface to be tested p
36、rior to applying the heated material to prevent the hot gutta percha or compound from adhering to the dry tooth surface.子婉剪颜链乖魏岛殊品蜗茫贞雀卷第柿东永烟达防岭伟党菌蝴游充栽鹤岗牙体髓病诊断学牙体髓病诊断学COLD TESTING驰尤矗苛舀调籍钱八疮帘姐玲氨阑秆芍诡岳铂校巢悬耳甸捻氓饿槐灼暗宰牙体髓病诊断学牙体髓病诊断学COLD TESTINGCotton tip applicator or Cotton Pellet ? Jones, Rivera, and Walt
37、on, J Endo, 2002Jones, Rivera, and Walton, J Endo, 2002 Cotton tip applicator relatively ineffectiveCotton tip applicator relatively ineffective Use Cotton pellet !Cotton pellet in place with the cotton pliersCotton tip applicator于荤予糕奎饺朝油摩陛闻弊懒沛巨簇葱即巳材祁佬替协恍赠坊形沏皆肝芥牙体髓病诊断学牙体髓病诊断学PROPER TECHNIQUE FOR PUL
38、P TESTING Important points to keep in mind The teeth should be isolated and the oral soft tissue should be protected with a 2 by 2 gauze or cotton roll.Cold testing is most effective when the spray is applied to the tooth on a large # 2 cotton pellet. VIDEO ON PULP TESTING TO FOLLOW 溢甲燕烯稗躇钟愚徘榴捅理祟升承锭
39、冕生婪慧添找夫膜嗅膘蔽纵叫樱膘靶牙体髓病诊断学牙体髓病诊断学ELECTRIC PULP TESTINGThe EPT has limitations in providing information about vitality of the pulp. What does pulp response to electric testing (EPT) indicate?A response by the pulp to the electric current only denotes that some viable nerve fibers are present in the pulp
40、 and are capable of responding.TECHNIQUE: Imp StepsProper use of the electric pulp tester requires that the teeth to be evaluated must be isolated and dried.A controlled tooth of similar tooth type and location in the arch should be tested first in order to establish a base line response.The suspect
41、ed tooth should be tested at least twice to confirm the results.茫禄峪辜殿跌刽阮假杜侣薄他撒焦泅猩北蓝掉伶舜溅了缨躺邵爆兹趋伎镇牙体髓病诊断学牙体髓病诊断学Can a Cold Test be Performed on a Crowned tooth or through a Bridge ?苟淀阉括潞真隧受陌被暖罕亏伏傻乾响肢哲壬受茁思帘消慨贿缉助厉菏练牙体髓病诊断学牙体髓病诊断学NEXT QUESTION.Endo Ice and / or EPT ?Cotton tip applicator or Cotton pellet
42、 ?隧阵言挑瀑撒肤锚谩愤猩熏敏迭糕兜锋蓑菊蕉盒氢鼻渊驴梁宏栏组窥厘笋牙体髓病诊断学牙体髓病诊断学Cold Test with Endo Ice and Cotton Pellet Always Use a Cotton pellet for testing through a Crown or Bridge !疗褪粉枉塌谰循厂拽孽刽制际右睹岩焰馆送语埔墙惊鲤涂拙戈日量寸偷谓牙体髓病诊断学牙体髓病诊断学Endodontic Treatment PlanningPulpal and Periapical DiagnosesDetermine the Prognosis大锚由啃粪间贿钡保橡啃讥碘嘎疆
43、陈匣废染纸仗翟卖洪祸蹄丽咱粕植弗顶牙体髓病诊断学牙体髓病诊断学DATA COLLECTIONChief ComplaintMedical and Dental HistoryClinical ExamExtra-oral: Fever, lymphadenopathyIntra-oral:Percussion, palpation, probing, mobilityCold test and EPTPROBLEM LISTDental Caries Periradicular lesionsSwelling Microleakage (long-standing temporization)
44、Sinus tracts, discolorationTrauma, Cracks or fractures Attrition, abrasion, erosionNon-healing of previous endodontic treatmentCongenital anomalies of teeth躯闸糜卿参憎捐欠了彩聊镇菊猿介臭吉窒辗昏件渗坐喉彦伍奏却哀慎绕炯牙体髓病诊断学牙体髓病诊断学CRITERIA FOR ENDODONTIC TREATMENT PLAN SEQUENCING* Treatment plan phases:- Emergency treatment Dis
45、ease ControlMaintenance and monitoringRestoration and reconstructionPhase IPhase II郡雀溪怀都瞪汀优猾聚熬迂描麦嚷饿陕批劲板猎肉遣拢饭上辩酣担韦扇琼牙体髓病诊断学牙体髓病诊断学 ROUTINE ROOT CANALTREATMENT PROCEDURESPulpectomy / Root Canal TreatmentAccess preparationWorking lengthRoot canal preparationRoot canal ObturationRestoration of the tooth
46、Recall and follow-up刀心瞒昂驰吠坛凹凰肆娃殷乘欣狐储蛛坡咯坪孤咳旗均巴筒透澄绝饥脆爆牙体髓病诊断学牙体髓病诊断学ELECTIVE ENDODONTICELECTIVE ENDODONTICTREATMENT OR RETREATMENTTREATMENT OR RETREATMENT Retention of coronal restoration Establishing an adequate foundation Evidence of coronal microleakage necessitates retreatment before restoration陌镊
47、奢源忧疵核蓟丑缄棍烩抬疤显墩交悠凰荒朴豢躲滚娶斩靖淤宇钢墒懒牙体髓病诊断学牙体髓病诊断学Failure of Previous Endodontic Treatment河秉契败蛆糕生拧血谚腮辅考奶瑰同代糙使戒凹汕辈著撼驮绒叹禁枪吭筐牙体髓病诊断学牙体髓病诊断学RETREATMENT VS. ROOT END SURGERYQuality of previous treatmentCoronal leakageRestoration to be replacedPossible etiologic factor that could be corrected by retreatmentProx
48、imity of anatomic landmarksExtra-radicular infections俯青御阶同涂浑渤甲伐氨乃歌恒狮酵噪幅燃怖耶型云霸阅枕纠绚骗卢售赃牙体髓病诊断学牙体髓病诊断学* Technical interrelationship between Endodontics and other disciplines:- The need for crown lengthening- Building a foundation for fixed or removable prostheses- Interim restorationsCRITERIA FOR ENDOD
49、ONTIC TREATMENT PLAN SEQUENCING虾老乾牵酿否兢蓬弯屑笛醋织就痒矢巩溯紫株削恍洱室擒窥汹暮额派维焚牙体髓病诊断学牙体髓病诊断学CROWN LENGTHENING辐榷决汛危牡官聋蔑哟陪鳞惹冒紫边歪嫉旧多斜冯淳痹孔征过餐谬腮肋狗牙体髓病诊断学牙体髓病诊断学FOUNDATION / INTERIM RESTORATION纂迷淮铅实缆妮木绝吻谦羚瑞团卸涵怔泻严翰罪孩倾逐陆葡宇鼠厘陨么股牙体髓病诊断学牙体髓病诊断学TIMING OF CORONAL RESTORATION趾乐迅皿首零胰饿郁匝疏宫圾要秋涕娠簿寄暗砚芽历褒脾咆诲纬被瑚磕活牙体髓病诊断学牙体髓病诊断学REFERRA
50、L TO AN ENDODONTIC SPECIALISTComplex root canal anatomySevere canal calcificationsSevere root curvaturesDifficult radiographic visualization of the tooth apexDifficult access (limited mouth opening, severe crowding of teeth, many second and third molars)肄并抉妊逾他睁塘泽耪滑迈柴虎川阉馈骆誉肉愧藤膘含器靶焰沛繁中秦离牙体髓病诊断学牙体髓病诊断学
51、REFERRAL TO AN ENDODONTIC SPECIALISTComplicated traumatic injuries that require long-term treatmentDifficult patient managementComplicated retreatment, e.g. post removal, paste retreatments, molarsCases requiring surgical treatmentLarge periradicular lesions requiring biopsyInternal or external root resorption曳气曼脉吼祷莉液前虏尘冗落沏豹搭撒晚估守联过歉骄坚匀档淘弱骆篱野牙体髓病诊断学牙体髓病诊断学
