diagnosis of pulp and periradicular disease 2012
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DIAGNOSIS OF PULP &PERIRADICULAR DISEASE
S.O.A.P
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First lesson on clinical dentistry
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Material for this presentation wasprovided by the following
Endodontics by Arnaldo Castellucci
Visual Endodontics and Traumatology
Robert Roda D.D.S
Torbinijad and Walton Endodontics 4 th edition
Endodontic Techniques ada c-e-r-pAlex Fleury
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S O A P
Rootamentoryinformation
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Endodontics
Deals with the diagnosis, prevention & ortreatment of periradicular disease It is concerned with the morphology
pathology and physiology of the dentalpulp and periradicular tissues
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According to recent data from the
American Association ofEndodontists.
82% of endodontics is performedby general practitioners. Therforethey make a majority ofendodontic diagnosis
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A systematic approach tocollecting information is critical foran accurate diagnosis andtreatment.
The SOAP approach to achievingthis diagnosis is an efficient andsimple method to utilize.
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S.O.A.P. Subjective Information Objective Findings Assessment Plan of Treatment
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S.O.A.P.SUBJECTIVE
Chief complaint-------Location & source of painHistory of pain
Frequency of the pain Stimulus/relief of the painDuration of the painSeverity of the pain
Spontaniety of pain
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Dental History Allows patient to voice his/her chief
complaint Allows patient input into the diagnostic
process Accelerates the clinicians determination
of the etiology of the chief complaint
Must be augmented by directed relevantquestions by the clinician
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S.O.A.P.
Objective Findings Clinical Examination Radiographic Assessment Comparative Testing
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The Examination
Extraoral Exam Methodical
Note asymmetries Pupillary dilitation or constriction Dermatologic presentation (lesions,
etc.) Lymph node palpation and TMJ
evaluation
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Intraoral Examination
Number and quality of existingrestorations
Discolored teeth Evidence of parafunctional habits Presence of disease (caries, periodontal
disease, etc.) Overall oral hygiene
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S.O.A.P. Objective Findings
Comparative Testing
Thermal Tests Cold (H2O, CO2, Endo Ice) Heat (Warm Gutta Percha)
Bite Test Electric Pulp Test Transillumination Anesthetic Test Test Cavity
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Pulp Vitality Tests
Intended to differentiate between a vitaland non-vital pulp
Normal teeth should be tested first to
establish a baseline for that patient Most gauge nerve fiber activity rather than
blood supply
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As An Aside
Not good in Primary Teeth
See Dr Creech
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Radiographs
Periapical views most often employed Customized stints allow reproducible
angulations and should be used for initial,final and recall films
Intraoperatively, the Endo-Ray is used
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Radiographic Interpretation Is the lamina dura intact? Is the bony architecture intact or is there evidence of
demineralization? Is the root canal system within normal limits or is
there resorption or calcification?
What anatomic landmarks could be expected in thisarea? Are the films of sufficient diagnostic quality? Several angulations may be needed Evaluate crown margins Look at number ,size, and shape of roots
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S.O.A.P.Assessment
Diagnostic Categories Should Correspondto Treatment- Oriented Categories
Diagnosis should indicate the pulpal andperiradicular status and the kind of treatmentneeded to rectify the problem.
(Gutmann e t a l , 1992)
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S.O.A.P.
Assessment
Pulpal Diagnosis Periradicular Diagnosis Non-Endodontic Pathology
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S.O.A.P.
AssessmentPeriradicular DiagnosisApical
Normal periradicular tissueSymptomatic apical periodontitis
Asymptomatic apical periodontitisAcute apical abscess
Chronic apical abscessCondensing osteitis
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possible new classificationsNormal apical tissues
normal tissue not sensitive to percussion ,palpation,lamina dura intactperiodontal space is uniform
Symptomatic apical periodontitis
inflammation present producing symptoms painful tobiting,percussion,palpation. may or may not have apical radiolucency
Asymptomatic apical periodontitis
inflammation and destruction of apical periodontium that is pulpal in originappears as an apical radiolucent area no symptoms
Acute apical abcess
inflammatory reaction to pulpal infection and necrosis . Rapid onset,spontaneous pain, tenderness to pressure, pus formation swelling
Chronic apical abscess
inflammatory reaction to pulpal infection and necrosis characterized bygradual onset, little or no discomfort intermittent discharge of pus through a sinustract
Condensing osteitis
diffuse radiopaque lesion is a bony reaction to low grade inflammationusually at apex of the tooth
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S.O.A.P. Assessment
Non-Endodontic Pathology Acute Periodontal Abscess Vertical Root Fracture Acute / Chronic Sinusitis TMD / MPD (incl. Occlusal Trauma)
Neuropathic Pain Vascular Pain Atypical Facial Pain
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periodontal abscess teeth are vital
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S.O.A.P.
Plan of Treatment Endodontic Therapy
Emergency Treatment Elective Treatment
Extraction Referral
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Pulpal States
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Normal Pulp &
Dentin hypersensitivity Normal is symptom free and responds normal
to testingDentin hypersensitivity
From exposed dentin More a symptom than a disease
Not due to caries etc. Due to thermal, chemical or tactile stimulus ? Not sure of cause hydrodynamic theory
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Reversible Pulpitis
Pulp is vital with some minor degree of inflammationMild symptoms or no symptomsMostly sensitive to cold
Pain rapidly subsides when stimulus is removedNo carious exposureNo sensitivity to percussionPain is not spontaneous or unprovoked
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Irreversible pulpitisSymptomatic Irreversible
Pulp is vital severely inflamedSymptoms usually intense acute could be chronicPain may be poorly localized
Pain is spontaneousPain to hot & cold (cold may make it feel better at later stages)Pain lingers after stimulus is removedMay or may not be sore to percussion
Normal PDL or may be thickenedAsymptomatic irreversible
No clinical symptoms but inflammation due to caries or traumaall carious exposures are considered under this category
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Necrotic PulpPulp is non-vital symptoms from asymptomatic
to intenseMay or may not have periradicular lesion
Non responsive to hot and cold and electric testsCan be percussive sensitive with the onset of
periradicular inflammation
May or may not show apical pathology
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Previously treated
The tooth has been endodontically treatedand the canals are obturated with variousfilling materials other then just intracanalmedicaments
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Previously Initiated Therapy
Tooth has been previously treated by partialendodontic therapy
pulpotomypulpectomy
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Periradicular Disease
Normal periradicular tissues
patient is asymptomaticPDL space is uniform in width
around entire root-intact laminadura.
But could also be necrotic!!!
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Periradicular Pathosis Consequence of pulpal necrosis Can range from slight inflammation to
extensive destruction of tissue
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Apical Diagnosis
Normal apical tissuesSymptomatic apical periodontitisAsymptomatic apical periodontitisAcute apical abscessChronic apical abscessCondensing osteitis
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Speed of resorption
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