Endodontic Assessments in a Differential Diagnosis The Endodontic- Restorative Continuum Alan H....

Endodontic Assessmentsin a Differential Diagnosis

The Endodontic-Restorative Continuum

Alan H. Gluskin DDSAlan H. Gluskin DDSProfessor and ChairProfessor and Chair

Department of EndodonticsDepartment of Endodontics

The Role of Endodontic Vitality Testing

in aDifferential Diagnosis

Endodontic Differential DiagnosisMedical / DentalMedical / Dental

Extraoral ExaminationExtraoral Examination

Intraoral ExaminationIntraoral Examination

Tactile ExamTactile Exam

Definitive DiagnosisDefinitive Diagnosis

Vitality TestsVitality Tests

RadiographsRadiographs

Extraoral Visual Examinations

Facial Facial Asymmetry Asymmetry

??Yes / NoYes / No

Aggressive Aggressive SwellingSwelling

??Yes / NoYes / No

Facial Facial InjuriesInjuries

??Yes / NoYes / No

Purulent Purulent DrainageDrainage

??Yes / NoYes / No

Intraoral Visual Examination

PalpationPalpation

RadiographsRadiographs

ProbingsProbings PercussionPercussionMobilityMobility

Palpation / Digital ExaminationPalpation ExaminationPalpation Examination

Light Digital PressureLight Digital Pressure

Soft TissuesSoft Tissues

LocationLocation

Indurated, Swollen Indurated, Swollen FluctuantFluctuant

Pain IntensityPain Intensity

No Pain, Tender, No Pain, Tender, Acute PainAcute Pain

Intraoral Visual Examination

OopsOops

Endodontic Assessmentsin a Differential Diagnosis

The Endodontic-Restorative Continuum

Alan H. Gluskin DDSAlan H. Gluskin DDSProfessor and ChairProfessor and Chair

Department of EndodonticsDepartment of Endodontics

Vitality Assessment & Tools

Thermal Thermal Cold HeatCold Heat

Vital Test Vital Test CavityCavity

Electric Electric Pulp Pulp

TesterTester

Selective Selective AnesthesiaAnesthesia

Tooth Tooth Slooth™Slooth™

Fiber Fiber Optic Optic LightLight

Tentative DiagnosisTentative Diagnosis

Establish A Point of Reference

Challenge Challenge Adjacent/ Adjacent/

Contralateral Contralateral ToothTooth

Challenge Challenge Opposing Opposing Tooth or Tooth or

ArchArch

Challenge Challenge Tooth in Tooth in QuestionQuestion

Challenge Challenge QuadrantQuadrant

Vitality Assessment & Tools

Thermal Thermal Cold HeatCold Heat

Vital Test Vital Test CavityCavity

Electric Electric Pulp Pulp

TesterTester

Selective Selective AnesthesiaAnesthesia

Tooth Tooth Slooth™Slooth™

Fiber Fiber Optic Optic LightLight

RadiographsRadiographs

Tooth Responses

Hypo Hypo ResponsiveResponsive

W.N.L. W.N.L. Hyper Hyper ResponsiveResponsive

Responses Responses From ToothFrom Tooth

(-)(-) (-) / (+)(-) / (+) (+ +) , (+ + +)(+ +) , (+ + +)

MomentaryMomentary LingersLingers SpontaneousSpontaneous

Endodontic Differential DiagnosisMedical / DentalMedical / Dental

Extraoral ExaminationExtraoral Examination

Intraoral ExaminationIntraoral Examination

Tactile ExamTactile Exam

Definitive DiagnosisDefinitive Diagnosis

Vitality TestsVitality Tests

RadiographsRadiographs

Dental History - The Science

•Recognize

•Understanding

•Interpreting

Dental History - The Art

•Asking the RIGHT questions

•ACTIVE listening

Dental Emergencies

Tooth Tooth TraumaTrauma

ToothacheToothacheNon-Pulpal Non-Pulpal

InvolvementInvolvement

Tooth Tooth Knocked Knocked

OutOut

Loose Loose ToothTooth

Fractured Fractured ToothTooth

Chipped Chipped ToothToothConcussionConcussion

Diagnosing Oro-facial Pain

•Dental

•Non-Dental

Interpreting the Language of Pain

Subjective Subjective ColoringColoring AcuteAcute ChronicChronic

Low Low Grade Grade PainPain

Hx of Hx of PainPainIntenseIntenseSharpSharpSpon-Spon-

taneoustaneousDeep, Deep,

GnawingGnawing

Understanding the Language of Pain

SignsSigns SymptomsSymptoms

DentalDentalNon-DentalNon-DentalDentalDental Non-DentalNon-Dental

++

Inflammation• Cellular

• Neurologic

• Vascular

• Humoral

Language of Pulp PainDental PulpDental Pulp

Pulpal InflammationPulpal Inflammation

AsymptomaticAsymptomatic SymptomaticSymptomatic

AcuteAcute ChronicChronic

Physiology of Pulpal Pain

A-Delta A-Delta FibersFibers

PainPain

Human Human Dental PulpDental Pulp

Afferent Afferent ImpulsesImpulses

C-FibersC-Fibers

Physiology of Pulpal Pain

• A-delta Fibers:–Located in Pulp-Dentin Interface

–Myelinated–Large Diameter

A-delta Fibers – Cold / HeatThermoreceptor for Pain

•Quick

•Sharp

•Short

Physiology of Pulpal Pain

• C- Fibers:

·Located Centrally in the Pulp

·Unmyelinated

·Small Diameter

C-Fibers - HeatThermoreceptor for Pain

• Steady

• Dull / Gnawing

• Prolonged / Spontaneous

Acute Pulpal OriginAcute Pulpal Acute Pulpal PainPain

Temporary Temporary PainPain

Short Short DurationDuration

ColdCold

AbscessAbscessSpontaneousSpontaneous

ConstantConstant Pres-Pres-suresure

Swell-Swell-inging FeverFever

HeatHeat IncreaIncrea-sing-sing

Cold Cold HotHot

ThrobThrob-bing-bing

Cold Cold ReliefRelief

DiffuseDiffuse LocalizedLocalized

Chronic Pulpal OriginChronicChronicPulpal PainPulpal Pain

DullDull IntermittentIntermittent RecurrentRecurrent

DeepDeep

AcuteAcute

TolerableTolerable

AcuteAcute

AcuteAcute

AcuteAcute

Endodontic Assessmentsin a Differential Diagnosis

The Endodontic-Restorative Continuum

Alan H. Gluskin DDSAlan H. Gluskin DDSProfessor and ChairProfessor and Chair

Department of EndodonticsDepartment of Endodontics

Mobility - DepressibilityExamination

Integrity

of the

Attachment Apparatus

Tooth Mobility EvaluationMobility Mobility

ExaminationExamination

Light Lateral Light Lateral PressuresPressures

Adjacent TeethAdjacent Teeth

Suspect TeethSuspect Teeth

Class IClass I Class IIClass II Class IIIClass III

Periodontal Ligament Reaction

TraumaTrauma

Vital PulpVital PulpNecrotic Necrotic

PulpPulp

P.D.L. P.D.L. ReactionReaction

HealthyHealthy SickSickEgressing Egressing

OutOut

Perio Perio DiseaseDisease

Egressing Egressing OutOut

Thermal Responses

Cold Stimulus ChallengeCold Cold TestTest

ToothTooth

Ethyl ChlorideEthyl ChlorideRefrigerantsRefrigerants IceIce

Hyper Hyper ResponseResponse

CarbonCarbonIceIce

W.N.L.W.N.L. Hypo Hypo ResponseResponse ReliefRelief

Cold Test

Heat Challenge

Heat Stimulus ChallengeHeat Heat TestTest

ToothTooth

Warm Gutta Warm Gutta PerchaPercha

Hot Tap Hot Tap WaterWater

Hyper Hyper ResponseResponse

Rubber Disc Rubber Disc FrictionFriction

W.N.L.W.N.L. No No ResponseResponse

Delayed Delayed ResponseResponse

EarlyEarly

Pulpal InjuryPulpal Injury

Thermal Thermal ChallengeChallenge

Normal PulpNormal Pulp Inflamed Inflamed PulpPulp Aged PulpAged Pulp

LateLate

Neural Responses

Electric Response AssessmentElectric Pulp Electric Pulp

TesterTester

Adjacent ToothAdjacent Tooth

Suspect ToothSuspect Tooth

Contralateral Contralateral ToothTooth

Hyper Hyper ResponseResponse W.N.L.W.N.L. Hypo Hypo

Response Response No No

ResponseResponse

Neuron Neuron ActivityActivity

Neural Neural ResponsesResponses

Vital PulpVital Pulp Necrotic Necrotic PulpPulp

Total Total NecrosisNecrosis

Partial Partial NecrosisNecrosis

Aged Aged TissuesTissues

Trauma Trauma to Pulpto Pulp

Young Young TissuesTissues

Sensory Pathways

Identifies Identifies Source of Source of

Tooth PainTooth Pain

Sensory Sensory PathwaysPathways

Identifies Identifies Referred Referred

Pain From Pain From ToothTooth

Identifies Identifies Non - Tooth Non - Tooth

PainPain

Anesthetic DiagnosisSelective Selective

AnesthesiaAnesthesia

Ligamental Ligamental InjectionsInjections Local AnesthesiaLocal Anesthesia

Relieves Relieves Suspect Suspect

ToothTooth

Regional Regional BlocksBlocks

Reveals Reveals Referral Referral

PainPain

Reveals Reveals Trigger Trigger SitesSites

Reveals Reveals Referral Referral

PainPain

Test Cavity Challenge

Test Cavity ChallengeTest CavityTest Cavity

No Anesthetic No Anesthetic

Prepare Shallow Prepare Shallow AccessAccess

Penetrate Into Penetrate Into Dentin / ChamberDentin / Chamber

No ResponseNo Response Slight ResponseSlight Response Acute ResponseAcute Response

Pulpal NecrosisPulpal Necrosis Degenerating PulpDegenerating Pulp Vital PulpVital Pulp

100% 100% HealthyHealthy

Extent of Extent of Pulp VitalityPulp Vitality

Test CavityTest Cavity

Vital PulpVital Pulp

Endodontic Endodontic AccessAccess

NecroticNecrotic

DegeneratingDegenerating

Fractured Tooth AssessmentTooth Tooth Slooth™Slooth™

Bite & ReleaseBite & Release

Sharp PainSharp Pain

Engage Cusp TipEngage Cusp Tip

Shallow Shallow FxFx Cuspal FxCuspal Fx Vertical Vertical

FxFxHorizontal Horizontal

FxFx

No PainNo Pain

Occlusal Provocation

Occlusal Occlusal ProvocationProvocation

Vital Vital ToothTooth

Damage Damage to Crownto Crown

NecroticNecroticToothTooth

Damage Damage to Rootto Root

Damage Damage to Rootto Root

Damage Damage to Socketto Socket

Crack Detection

Tooth Slooth™Tooth Slooth™

Checking for crack/fracture

Crack MB cusp

Deep isolated pocket

Transillumination

TransilluminationFiber Optic Fiber Optic Light ExamLight Exam

Thru Cervical Thru Cervical LineLine

Light Light ConductanceConductance

Through & Through & ThroughThrough

Abrupt Abrupt StoppageStoppage

Surface Surface CrazingCrazing

Thru Line Thru Line AnglesAngles

Thru Cusps Thru Cusps TipsTips

Superficial Superficial CracksCracks

TransilluminationTransillumination

Hard Tissue Hard Tissue IntegrityIntegrity

Deep Deep FracturesFractures

Moderate Moderate CrazingCrazing

Acute Crack

MisdiagnosisMisdiagnosis

The Endodontic-Restorative Continuum

Decision Making

Diagnosis Prognosis

Treatment

Decision Making

Diagnosis Prognosis

Treatment

Host ResistanceEndo - PerioPatient Dental I.Q.Operator Limitations

How Critical is Tooth? Cost EffectivenessTreatment Alternatives Sequence of Treatment Use of Specialist

HistoryEtiologyEndo and / or Perio

Determination of Prognosis

• Periodontal Prognosis

• Endodontic Prognosis

• Restorative Prognosis

Periodontal Prognosis

• Bone loss

• Pocketing

• Health of Periodontium

Periodontal Concerns

• General periodontal status

• Isolated periodontal defect

Endodontic Prognosis

• Vitality

• Periapical area

• Canals negotiable?

• Posts present?

Endodontic Diagnosis Vital Tooth

•Reversible•Irreversible

Electric Pulp Tester

Cold Test

Cold Test

Tooth Restorability • Caries

• Chip in enamel

• Chip into dentin

• Cusp fracture

• Tooth fracture

• Root amputation

Restorative Prognosis determined by…

Structural IntegrityStructural Integrity

Treatment AlternativesRestore as is...

Restore as is... and extract

Extract–No further treatment–Fixed partial denture–Removable partial denture–Implant

and hopeand hope

Financial Considerations

•At UOP

•In Private Practice

Ferrule Effect

• What is it?

• Facial/Lingual vs Mesial/Distal

• Anterior Tooth

• Posterior Tooth

• How wide / thick?

How to achieve the ferrule

• Prep into sulcus

• Crown lengthening

• Extrusion

FerruleFerrule• 11.5 -2 mm long.5 -2 mm long

• Parallel wallsParallel walls

• Totally encircle toothTotally encircle tooth

• End on sound tooth surfaceEnd on sound tooth surface

• Not invade attachment Not invade attachment apparatusapparatus

CoreCore• Replaces missing Replaces missing

tooth structuretooth structure

• Supports rehabilitationSupports rehabilitation

Core MaterialsCore Materials

• Cast metalCast metal

• AmalgamAmalgam

• Composite resinComposite resin

• Glass Ionomer / Glass Glass Ionomer / Glass Ionomer Silver materialsIonomer Silver materials

Fractured Cusp into Furcation

Crown/restorative disassembly

Tooth isolated for endodontics

Resin syringe

Build-up matrixed

Crown lengthening

Post-op crown lengthening

Post-op crown lengthening