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D435 Endodontics I

D435 Endodontics I. Lecture 4 Clinical Diagnosis of Periapical Disease Text-Ch1(36-37), Ch2(51-55), Ch14 pp541-573. Abbreviation guide. P/A=Periapical PA XR=Periapical X-ray PT=Pulp test Previous- AP, AAA, AAP, CAP WNL=Within normal limits FM =full mouth series of X-rays

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D435 Endodontics I

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  1. D435 Endodontics I Lecture 4 Clinical Diagnosis of Periapical Disease Text-Ch1(36-37), Ch2(51-55), Ch14 pp541-573

  2. Abbreviation guide • P/A=Periapical • PA XR=Periapical X-ray • PT=Pulp test • Previous- AP, AAA, AAP, CAP • WNL=Within normal limits • FM =full mouth series of X-rays • DST=Draining sinus tract • T-PDL=Thickened Periodontal Ligament

  3. OUTLINE 1. “Clinical” Periapical (P/A) Diagnosis 2. Clinical Periapical Diagnostic “Boxes” 3. Objective Clinical Testing for P/A Disease 4. Dental Radiography

  4. Why “Clinical” Periapical Diagnosis? To convince you to NOT diagnose from the PA XR--- WHY? Some entities can mimic “Lesions of Endodontic Origin” (LEO)’s If PTs indicate WNL, & pt is asymptomatic, biopsy may be indicated But….one cannot take a periapical biopsy to determine histological status without disturbing the blood supply to the tooth and…….. Such an action will probably create the need for RCT or extraction.

  5. NOW, can you point to the tooth that hurts? Probably yes, but why?

  6. Objective Testing for P/A disease • Facts: • Unlike the Pulp, the periodontal ligament (PDL) contains proprioceptive fibers* which means the tooth can now respond to percussion if inflamed or infected. • So what? • This allows the patient and the operator to locate the source or pain if it has extended to the periapical tissues. . . . . . . .How? • Because the inflamed/infected PDL will become sensitive to percussion/biting and can be easily located by percussion. • NOW…The patient can usually point to the offending tooth

  7. Periapical Diagnostic “Boxes” If we think of the periapical tissues as a separate entity, There are ONLY these Possibilities: Normal Inflamed Infected (= Abscessed) WNL AcuteApical Periodontitis (high filling vs. early abscess) AAP AAA Acute Apical Abscess Chronic Apical Abscess (Chronic Apical Periodontitis) CAA CAP Consider these (=)

  8. AAP, CAA (CAP), AAA, “Phoenix Abscess”. All are on this slide! Diagnosis depends Upon patients SYMPTOMS!

  9. Periapical Diagnostic “Boxes” WNL Within normal limits P/A Tissues : WNL No CC, No Symptoms Pulp tests WNL Negative to percussion No apical radiographic changes PATIENT IS ASYMPTOMATIC

  10. Acute apical periodontitis AAP Acute P/A Tissues : AAP CC : Tooth acutely sensitive to percussion/biting, with NO swelling Pulp Vital (thermal sensitivity variable) No apical radiographic changes OR possible thickenedPDL space. Probable etiology: occlusion from recent restoration, history of trauma?…..OR early AAA prior to swelling

  11. Chronic apical periodontitis Chronic apical periodontitis/abscess: CC : Negative/mild sensitivity to percussion/biting Pulp non-vital if of pulpal origin Pain to percussion variable (generally negative) unless…… Thickened PDL space or MORE LIKELY, P/A radiolucency CAPCAA

  12. Acute apical abscess: AAA CC : Tooth VERYpainful to percussion/biting + SWELLING present (intra-oral or extra-oral) Febrile Pain to percussion= VERY SEVERE! Pain to palpation=moderate to SEVERE Pulp USUALLY NECROTIC No apical radiographic changes or possibly thickened PDL space. Usually Mobile due infection at apex Usually swelling and fever

  13. Periapical Diagnostic “Boxes” CAP AAA AAA can arise from CAP as the mythical bird Phoenix arose from its own ashes. Therefore, we call this a Phoenix, Recrudescent or Recurrent abscess . BUT.. it is STILL an AAA!

  14. Suppurative chronic apical periodontitis S-CAP CC : Tooth mild to no sensitivity to percussion/biting Generally little swelling-this is a drainingsinus tract (DST) Pulp non-vital Pain to percussion=mild or none Radiographic changes : well-established P/A lesion

  15. Always trace out a DST w gutta percha cone… sometimes you can be fooled!!!!

  16. Objective Clinical Testing for P/A disease • Percussion+ • Palpation? • Mobility? • Periodontal Probing • Radiography * Facts: NOW the patient can frequently POINT to the offending tooth, WHY ? Proprioceptive fibers

  17. Objective Clinical Testing for P/A problems • Percussion:This is arguably our most valuable exam procedure in PERIAPICAL diagnosis.

  18. Objective Clinical Testing for P/A • Percussion:Progress from GENTLE to mild percussion with a mirror handle. • Percuss: • Occlusal • Facial

  19. Objective Clinical Testing for P/A • Palpation: • Gently feel the tissues looking for tenderness, swelling, unusual texture or composition.

  20. Objective Clinical Testing for P/A • Periodontal Probing: • Probe 6 areas each molar tooth. (Why?) • Probe several teeth • Look at the tissues (inflamed?) DST

  21. To re-iterate: • Plan your pulp/peri apical testing to match the patients symptoms • Cold, heat, percussion, palpation • Electric pulp test (EPT) only to determine patient response when you suspect that a tooth has gone necrotic AND this test isn’t always accurate either

  22. Vertical Root Fracture Look for J-Shaped apical lesion Look for Drop-off Pocket if . . . . VRF difficult to confirm radiographically –UNLESS separation of segments occurs

  23. Classic “J” endo lesion,(NOT a VRF)

  24. 1. Of 92 cases of known VRF, a lateral radiolucency or a combo of lateral & PA radiolucency (‘J’ lesion), was found in over one half of the cases… Radiographic Evaluation of Endodontically Treated Vertically Fractured TeethA. Tamse et al. JOE July ’99 p506,… 2. Wideningof the PDL on one or both sides of the root was found in 18% of cases 3. In twelve of these cases, NO radiolucency was found!

  25. 4. Dental Radiography • Maybe the most important tool we have in helping to determine Periapical Diagnosis, according to Dr. Frank Weine However,………..

  26. 4. Dental Radiography • At least 2 P/A views (straight & angled) WHY? • One carefully aligned B/W.. WHY? • What are DiagnosticQuality films ?

  27. 4. Dental Radiography : • What are DiagnosticQuality films ? • P/A must show entire tooth and surrounding structure (at least 2 mm. beyond apex or the complete lesion) This NOT THIS!

  28. NEXT WEEK, Sept 19Endodontic Radiology 101 • OR…You can’t tell the LEO’s from normal anatomy or systemic pathology without a program !!! • Dr. Shara Dunlap Ch1 (20-23,) Ch (95,96-98,109) • Blackboard

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