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Diagnosis and Treatment Planning

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 Diagnosis and treatment planning 

³Discovery lies in seeing what everyone else sees, but thinking what no one has thought´ According to Stedmans Medical Dictionary diagnosis is defined as ³ the determination of the nature of a disease made from a study of the signs and symptoms of a disease.´ Diagnosis if often derived from personal and cognitive experiences. The most important assets of  a diagnostician being knowledge, interest, intuition, curiosity and patience. Since many diseases have similar symptoms, Differential diagnosis is the most common   procedure. This technique distinguishes one disease from several other similar disorders by identifying their differences. Diagnosis by exclusion, on the other hand eliminates all possible diseases under  consideration until one remaining disease correctly explains the patients symptoms. Symptoms:

They are defined as phenomena or sings of a departure from the normal and indicative of illness. Symptoms can classified as follows: Subjective symptoms: Those experienced and repored to the clinician by the patient. `

Objective symptoms: Those ascertained by the clinician through various tests.

istory  H istory Case

history is defined as the data concerning an individual and his or her family and environment , including the individual medical history that may be useful in analyzing and diagnosing his/her case or for  instructional purposes. ³Anamnesis´ meaning ³recollection´ or ³calling to memory´ is the first step in arriving at diagnosis is recollection of the patients signs and symptoms, past as well as the present. A complete history will often modify endodontic treatment and may even determine the total treatment. It seldom denies treatment. Once the status of patients¶ general health is established dental history follows. This is best developed by following the time-honoured formula of determining chief complaint, enlarging on this complaint with questions of present dental illness, relating the history of past dental illness to the chief  complaing and combining this with information about the patients general health.

Chief complaint:

The reason the patient is seeking care. It is documented in the patients own words of incase of  minor, the parents or guardians words. This is often aided by hand gestures and patient pointing to genetal area of discomfort. Treatment should not be rendered unless the clinician is certain of diagnosis.

 Present dental illness:

It should help determine the severity and urgency of the problem. Questions should be put forth in a manner that leaves them open for patient discussion. Closed question should be avoided. The initial questions should help establish two basic components of pain: time(chronicity ) and severity(or intensity). Start by asking such questions as ³How long have you had this problem?´ ³how painful is it?´ ³how often does it hurt?´ continue the questioning with ³When does it hurt?´ ³When does it go away?´ ³What makes it hurt?´ ³What makes it hurt worse?´ and ³What makes it hurt less or go away?´ ³What medications have you taken´? This will help in assessing the pain intensity level and intergence with testing results.  Medical history:

Particular emphasis must be place on illness, history of bleeding, and medications. Illness often means hospitalization to patients; consequently they may not list weight changes, accidents or problems related to stress and tension. The term bleeding is usually interpreted as frank blood and seldoms related bruising or healing time. Chronic use of aspirin or history of liver disease should be

thing of concern. Medications i.e pills and drugs like diet pills, sleep inducers and vitamins should be asked. Women should be asked if they are pregnant or nursing, or if they menstrual or menopausal problems. Clinical examination:

It should follow a logical sequence, from general to specific, from more obvious to less obvious, from external to internal. Vital signs i.e. Blood pressure, Pulse rate, Respiration, Temperature should be done Cancer

screening must be routinely done for every new patient

Extra-oral examination: Patient must be examine for asymmetries, localized swelling, changes in color or bruises, abrasions, cuts or scars and similar signs of disease, trauma or previous treatment.  Intra-oral examination:

Lips and cheeks are retracted while teeth in occlusal contact, oral vestibules and buccal mucosa are examined for localized swelling, sinus tract, or color changes. With patients jaws apart evaluate lingual and palatal soft tissues. Finally carious lesions, enamel fractures, discolorations and other obvious abnormalities associated including loss of teeth and supernumerary and retained deciduous teeth noted.  Diagnostic testing:

The overall goal of diagnostic testing is twofold. First is to gain objective data from the patient¶s signs and symptoms as well as from the results of diagnostic testing. The second is to reproduce the  patients chief complaint, if patient has had past painful episodes. Thermal testing: Commonly

employed diagnostic tests.If properly done than have been proven to be reasonably effective.

Two types of heat stimuli tests are available namely heat and cold stimuli tests.

Ice has been used for cold thermal tests as it is readily available and inexpensive. Shortcoming being melted ice water can spread to either soft tissue or another tooth and cause false positive result. Cold

tests are most likely to give positive response in the cervical area compared to occlusal area. i.e.is related to the response is related to the thickness and type of tooth structures between the source of the cold and the pulp. Materials employed with temperatures colder than ice include skin refrigerant, Endo ice, carbon dioxide snow, and Spray and Stretch (dichlorodifluoromethane). Skin refrigerant produces greater thermal change (58.4 oF) than ice water(69.2 0F) or an ice stick(75.4 0F) Endo Ice (Tetrafluoroethane) is approximately -50 0F. Available in a convenient spray, applied to the tooth using a cotton pellet. It produces the greatest temperature reduction in intact teeth and those restored with gold, porcelain fused to metal and porcelain crowns, when tested for less than 15 seconds. Fuss et al stated the in vivo effectiveness of EPT, CO2, dichlorodifluoromethane, ethyl chloride, or ice and reported that CO2, dichlorodifluoromethane, EPT were the most dependable, while CO2, dichlorodifluoromethane were more effective in young patients. Carbon

dioxide snow/dry ice was introduced by Obwegeser and Steinhauser in 1963 and  popularized by Ehrmann. It has a temperature of -780C. Augsburger and Peters reported that it produced no cracks or fissures in enamel human teeth in vitro after being subjected for 15, 45, and 60 seconds on same spot on enamel. Warm thermal test  Not employed as frequently as cold testing as most patients are more sensitive to cold stimuli and moreover heat tests are difficult to perform. Involves making use of a heated ball burnisher, rotating Burlew rubber wheel, heated base plate gutta-percha or warm water. Flooding the tooth with warm water(1360F) under rubber dam isolation is the best method causes a temperature rise of approx 7 0F. System B allows the dentist to set specific temperatures for warm thermal testing. After surgace of tooth is lubricated, a hot pulp test tip can be attached to handle of System B and temperatures set at 1500F.  E lectric

Pulp Testing:

The EPT gauges the ability of nerves in the pulp to respond to electrical stimulation. The patient feels a warm, tingly burning or pain sensation due to A-delta nociceptors. The EPT gives the clinician no information on the status of inflammation in the pulp or the health or disease of the vascular system. The clinician should evaluate contralateral teeth as control teeth. The probe tip should be placed on occlusal two thirds on the lavial or buccal surfaces of teeth. The threshold increases as the proe tip is moved toward the gingival margin. Van Hassel and Harrington reported that precaution should be taken to prevent the current from spreading to adjacent teeth, especially those with contacting metal fillings. Multi-rooted teeth have the greatest chance of giving false readings.

Mumford reported that the shape of the area produced by current is triangular with base at the interface between pulp tester tip and enamel, with apex towards pulp. Teeth with incompletely formed apices require greater amount of current because of greater cross sectional area of pulp.  Newer instruments introduced since 1980¶s use either battery or A C source. Cooley et al reported that the Analytic Technology pulp tester includes following enhancements like ability to turn on and off  automatically when contacted the tooth and removed, a numerical digital display, a red light on the probe handle indicating that good contact with tooth is made and voltage is electronically stabilized. Petroleum jelly or water-based helly is the most conductive of the materials including toothpaste, saline pads, prophylaxis paste and direct contact with no media. Dry contact does not evoke any response. The circuit between the EPT instrument is closed by contact of clinicians ungloved hands or a lip clip in contact with the patients lips, cheek or gingival. A clinician may need to use EPT on full coverage tooth whereby a small metal endodontic instrument such as files, explorers or like could be used as bridging  procedure.  Percussion:

It is one of the oldest pulp vitality tests used because it requires no armamentarium. Percussion is an indirect means of testing pulp vitality because teeth that are sensitive to percussion often have existing  periapical lesions associated with a necrotic pulp. But, this is not foolproof as false positives can result if  clinician is evaluating a cracked tooth or a high restoration. Another alternative to percussion is application of digital pressure whereby to begin with, control tooth and then the tooth to be tested are compressed into the socket with increasing force until the clinician is assured the tooth is not sensitive to  percussion. Advantage being that mobility of the tooth can also be assessed simultaneously.

 Mobility:

Miller Index is an objective system to use and results can be easily communicated. Class

I: First distinguishable sign of movement greater than normal.

Class

II: Movement of the tooth as much as 1 mm in any direction.

Class

III: Movement of the tooth more than 1 mm in any direction and/or depression or rotation of the

tooth.  Palpation:

Extremely helpful in identifying areas either sensitive to touch or altered due to developmental reasons, disease or trauma. It should always be done bilaterally both the area in question and contralateral side. Bilateral palpation is important for several reasons. First: Subtle changes in anatomy often cannot be detected unless both ipsilateral and contralateral areas are evaluated simultaneously.

Second: Swelling on ipsilateral side may appear to be significant until the contralateral side is palpated at the same time. Third: Consistency of either a neoplastic or inflammatory swelling can be best assessed. Transillumination:

Diagnostic uxe was reported in 1927 when Cameron reported its use. Primarily used to help determine the presence of a crown or root fracture, can also aid to determine pulp vitality. Wherein a normal tooth exhibits yellow, white and pink hues and necrotic pulp exhibits a darker brown or black  color. To evaluate a tooth for crown fracture, dental unit light is turned off and only fibreoptic light used. If a crack is present in dentin the light will be interrupted and appears as dark line on the other side of the tooth. If a crack of this type is observed the tooth may exhibit symptoms such as sensitivity to thermal stimulation and mastication and/or percussion. These require a full coverage restoration and such fractures are often referred as ³Greenstick fractures´. Periodontal probing: The tooth should be evaluated interproxiamlly as well as in atleast three locations on both the  bucal and lingual surfaces. Harrington et al reported criteria states that if the periodontal probe sinks abruptly into an isolated   periodontal defect, the level of suspicion for vertical root fracture increases. Conversely, if probe sinks gradually than generalized periodontal condition chances increase. The following Glickman Classification system is commonly used for furcation defects: Grade I: Incipient lesion when the pocket is suprabony involving soft tissue and there is slight bone loss. Grade II: Bone is destroyed on one or more aspects of the furcation but a probe can only penetrate  partially into the furcation Grade III: Intraradicular bone is completely absent but tissue covers the furcation. Grade IV: A through and through furcation defect. Anesthetic test: This test is restricted to patients who are in pain at the time of the test when the usual tests have failed to identify the tooth. The technique involves using either infiltration or intraligament injection starting most posterior tooth until pain is relieved. If pain persists, anesthetize tooth mesial to it. In case of vague pain an infra alveolar  nerve block can be made use of.

Test cavity:

It is performed when other methods of diagnosis have failed. The test cavity is made by drilling through the enamel-dentin-junction of an unanesthetized tooth. If sensitivity or pain is felt by patient it is an indication of pulp vitality. Sedative cement is then placed in the cavity.  Recent trends:  Pulse oximetry:

It is a non-invasive method to measure the oxygen saturation levels during the administration of  anesthesia or other medications with help of a finger, ear, or foot probes. The pulse oximeter sensor consists of two light emitting diodes , one to transmit red light(660 nm) and the other to transmit infrared light (940 nm). And a photodetector on the opposite side of the vascular bed.  Measurement of tooth surface temperatures:

The pulp circulation is much more efficient than supporting tissue circulation in maintaining the temperature of the crown in vitro. The Hughes Probeye 4300 thermal video system is sensitive enough to measure temperature changes of as little as 0.1 0C. This principal can be put to use when teeth are cooled  by air spray to approximately 220C and then allowed to re-warm to their original resting temperature of  approximately 290C, the teeth containing normal pulp take about 5 seconds to re warm compared to 15 seconds by root filled teeth.  Diagnostic imaging:

Endodontic radiography: Wilhelm Konrad Roentgen discoevered the cathode rays in 8 th of November 1895. 14 days later  Dr.Otto Walkoff took the first dental radiograph in his own mouth. In 1900 Dr. Weston A Price called attention to incomplete root canal fillings as evidenced in radiographs, and also developed the bisecting angle technique, whereas Kells described the paralleling technique made popular by Dr. Gordon Fitzgerald 40 years later. Application of radiography in endodontics Aid in diagnosis of hard tissue alteration of teeth Determine the numver location shape size and direction of roots and root canals Estimate and confirm the length of canals Localize hard to find pulp canals Aid in locating a pulp space markedly calcified and/or receded. Confirm

position and adaptation of master cone

Aid in evaluation of obturation

Facilitate the examination of soft tissues for tooth fragments and other foreign bodies following trauma Aid in localizing a hard to find apex during root end surgery Evaluate, in follow up films, the outcome of treatment.  Limitations of

radiographs:

Radiographs are two dimensional shadows on a single film. They are suggestive only and are not the singular final evidence. The greatest fault with radiograph relates to its physical state. As with any shadow these dimensions are easily distorted through improper technique, anatomic limitations, or    processing errors. In addition the bucco-lingual dimension is absent, periradicular soft tissue lesions cannot by accurately diagnosed. A common misconception is that an inflammatory lesion is present only when there is at least a   perceptible thickening of the periodontal ligament space. In fact lesions of the medullary bone often go undetected unless there is marked resorption of has eroded a portion of cortical plate. Technology

systems.

Basically two radiographic approaches are available: Traditional X ray exposure of film chemically processed to produce an image X ray generated image that electronically processed and reproduced on computer screen Advantages of digital radiography include reduced radiation, speed of obtaining the image, enhancement of the image, computer storage transmissibility and a system that does not require chemical processing. Disadvantages are cost and more difficulty in placing the sensor. Traditional

machines:

Two basic types of Xray commonly used in dental offices. One type has a range of kilovoltage and two milliamperage settings with which long cone is frequently used. The long cone machine is preferred for exposing diagnostic, final and follow up radiographs The other type offers only one kilovoltage and milliamperage setting and only short cone Short cone machine with a small easily manipulated head saves time energy and used for working length determination. Intraoral film placement: There a number of devices, the  Rinn XCP is the best, but cannot be used with rubber dam in place. endoray II endodontic film hoder can be used with rubber dam in place.

 Rinn

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