DIAGNOSIS AND TREATMENT
PLANNING
Diagnosis:
Diagnosis plays a major role in any branch of
dentistry.Stedman’s Medical Dictionary describes
clinical diagnosis as ‘‘the determination of the nature
of a disease made from a study of the signs and
symptoms of a disease.’’ Accurate diagnosis of the
patient condition is essential before an appropriate
treatment plan can be formulated for an individual.
For an appropriate diagnosis all the signs, symptoms
and history of the patient is necessary to initiate a
treatment plan. It includes :
• Chief complaint
• History of present illness
• Medical history
• Clinical examination
• Investigations
• Differential diagnosis
• Treatment plan
CHIEF COMPLAINT:
• The chief complaint is the reason the
patient is seeking care.
• It is usually documented in the patient’s words, or in the
case of a young minor, the parent’s or guardian’s words.
• After obtaining the chief complaint, the examination
process is continued by obtaining a dental history of the
present illness. This helps establish the correct diagnosis.
HISTORY OF PRESENT ILLNESS
• A history of the present illness should help
determine the severity and the urgency of the
problem.
• Information about any recent dental treatment
should be obtained.
• Questions should be posed in regard to the character
of pain, its location, what initiates or relieves the
symptoms, the duration of the symptoms, and what
medications the patient is taking to alleviate the
symptoms.
MEDICAL HISTORY
• In reviewing the medical history, particular
emphasis must be placed on illnesses, history
of bleeding, and medications.
CLINICAL EXAMINATION
EXTRAORAL
• Asymmetries
• Localised swellings
• Bruises,abrasions,cuts,scars
• Trauma
• Lymphadenopathy
• Tmj disorders
INTRAORAL
• General evaluation
• Soft tissue examination: oral vestibules and
buccal mucosa are examined for localized
swelling,sinus tract or colour changes.
• Hard tissue examination:Carious lesions
,enamel fractures,discolorations,other
abnormalities of teeth including loss /retained
deciduous teeth.
Coronal evaluation
• Most obvious tooth is examined first.
• Mouthmirror,explorer, fiber-optic light are
used for examination.
• Examine tooth for caries,defective restorations
,enamel loss,periodontal problems &mobility.
• Fracture or teeth are examined by
transillumination and bite test with tooth sloth
and wet cotton roll.
PULPAL DIAGNOSIS
Classification of diseases of pulp
1.INFLAMMATORY DISEASES OF PULP
a)Reversible pulpitis
b)Irreversible pupitis
i) Symptomatic irreversible pulpitis
ii)Asymtomatic irreversible pulpitis
iii)Chronic hyperplatic pulpitis
iv)Internal resorption
2.PULP DEGENERATION
a)Calcific degeneration(radiographic)
b)Atrophic degeneration(histopathologic)
c)Fibrous degeneration
3.PULP NECROSIS
Normal pulp
This is clinical diagnostic category in which
pulp is symptom free and normally responsive
to vitality testing. The normal pulp may exhibit
a strong response but is not painful.
Reversible pulpitis
When the pulp with in the tooth is irritated so
that the stimulation is uncomfortable to the
patient but reverses quickly after irritation ,it
is classified as reversible pulpitis.
CAUSES:
• Caries
• Exposed dentin
• Recent dental treatment
• Defective restorations
Symptoms :
• Indicates that inflammation should resolve and pulp return
to normal.
• Increased response to cold,sweets
• Pain is always specific to a stimulus
• Pain relieved on removal of stimulus
Diagnosis :
• As the pulp is sensitive to cold ,application of cold is
excellent method of locating and diagnosing involved tooth.
• Tooth reacts normal to percussion,palpation,mobility
• On radiographic examination periapical tissue is normal
Treatment :
• Thr best treatment for reversible pulpitis is
prevention.
• Removal of noxious stimuli will bring the pulp
back to a healthy state.
Irreversible pulpitis
It is defined as the point where an inflammed
pulp is no longer capable of healing and
returning to normal.
TYPES
i) symptomatic irreversible pulpitis
ii)asymptomatic irreversible pulpitis
Symptomatic irreversible pulpitis
Symptoms :
• Teeth exhibit intermittent or spontaneous pain.
• Rapid exposure to temperature changes elicit prolonged episodes of pain
even after stimulus has been removed.
• Sharp,dull loaclised ,diffuse or referred pain
• Postural pain due to increase in intrapulpal pressure when patient changes
position from standing posture to supine.
• Nocturnal pain
Diagnosis :
• On radiographic examination no periapical changes.
• With advanced irreversible pulpitis show thickening of periodontal ligament.
• Deep restorations,caries,pulp exposure and any direct or indirect insult to
pulp are present on radiograph
Asymptomatic irreversible pulpitis
Symptoms :
• Deep caries will not produce any symptoms.
• Exposed pulp exhibits little or no pain.
Diagnosis :
• More current is used to elicit a response to
electric pulp test than control tooth.
• On radigraphic examination, caries may extend
well into pulp but no periradicular changes.
Treatment :
• Treatment consists of complete removal of
pulp or pulpectomy.
• In posterior tooth ,in which time is a
factor,removal of coronal pulp or pulpotomy
should be performed as an emergency
procedure.
• Surgical removal should be considered if tooth
is not restorable.
Chronic hyperplastic pulpitis
• Also called pulp polyp
• Growth of pulp tissue fron pulp chamber that is usually
covered by epithelium.
• Seen in young population in both primary and
permanent dentition.
Causes :
• Slow progressive exposure to pulp
• Large open cavity ,young,resistant pulp
• Mechanical irritation from chewing &bacterial infection
often provide stimulus.
SYMPTOMS :
• It is symptomless ,except during mastication,when pressure of
food bolus may cause discomfort.
• Fleshy reddish pulpal mass fills most of the pulp chamber or cavity.
• In early stages it may be the size of pin.
• Tissue bleeds easily because of rich network of blood vessels
DIAGNOSIS :
• Radiographs show large open cavity with direct access to pulp
• Electric pulp testing ,tooth responds to more current than normal .
TREATMENT :
• Elimination of polyploid tissue & extirpation of pulp
,tooth can be restored.
• Pulpal mass is removed with a curette or spoon
excavator,bleeding can be controlled with pressure.
• Pulp tissue is completely removed &temporary dressing
is sealed in contact with radicular pulp tissue.
• Radicular pulp is extirpated in next visit.
• If time permits,pulpectomy can be completed in single
visit.
INTERNAL RESORPTION
Internal resorption is an idiopathic slow or fast
progressive resorptive process occuring in the
dentin of pulpchamber or in root canals of teeth.
SYMPTOMS :
• Asymptomatic
• Crown shows reddish area called PINK SPOT
• Reddish area represents granulation tissue
showing resorbed area of crown.
RADIOGRAPHIC DIAGNOSIS :
• It is usually diagnosed in routine radiographs
• Radiograph shows change in appearance of wall in rootcanal or
pulpchamber,with round or ovoid radiolucent area.
TREATMENT :
• Extirpation of pulp stops internal resorption
• Routine endodontic treatment but obturated with plasticized gutta
percha method.
• In many patients ,as it is painless ,it progress to root perforation—
MTA is recommended to repair defect .
• As the defect is repaired it is obturated with plasticized gutta percha
PULP NECROSIS
It is a clinical diagnostic category,indicating
partial or complete death of dental pulp.This
could be due to persisting inflammation of
pulp tissue.
SYMPTOMS :
• Nonresponsive to vitality testing
• Pain free ,although painful to heat stimuli.
RADIOGRAPHIC DIAGNOSIS :
• Shows large cavity or filling,an open approach
to root canal.
• Thickening of periodontal ligament.
TREATMENT:
Pulpectomy( complete removal of pulp) and
obturating canals
PERIAPICAL DIAGNOSIS
Classification of periapical diseases
1.Symptomatic periradicular diseases
a)Symptomatic apical periodontitis(acute)
i)vital tooth
ii)nonvital tooth
b)Acute alveolar abscess
c)Phoenix abscess
2.Asymptomatic periradicular diseases
a)Aysmptomatic apical periodontitis(chronic)
b)Chronic alveolar abscess
c)Radicular cyst
d)Condensing osteitis
3.External root resorption
4.Persistent apical periodontitis
5.Diseases of periradicular tissues tissues of nonendodontic orgin
ACUTE APICAL PERIODONTITIS
(SYMPTOMATIC)
Painful inflammation of periodontium as a result
of trauma,irritation,or infection through root
canal, regardless if whether pulp is vital or non
vital.
SYMPTOMS :
• Shorter onset and cause mild discomfort
• Tender on percussion
• Tooth may feel extruded and may have pain on
mastication
RADIOGRAPHIC DIAGNOSIS :
• No radiographic changes
• Sometimes widening of pdl space
TREATMENT :
• Determining the cause and releiving symptoms.
• Determine whether apical periodontitis is
associated with vital or pulpless tooth
• When acute phase has subsided,tooth is treated
with conservative means.
ACUTE APICAL ABSCESS
Also called acute alveolar abscess
SYMPTOMS :
• Rapid onset,spontaneous pain,tenderness of tooth
to pressure
• Pus formation
• Eventual swellings of associated tissues
RADIOGRAPHIC DIAGNOSIS :
• Slight widening of pdl space and loss of apical
lamina dura of involved pulpless tooth
TREATMENT :
• Immediate treatment consists of drainage
• After the symptoms subside ,endodontic
treatment is proceeded
CHRONIC APICAL ABSCESS
Also called chronic alveolar abscess
SYMPTOMS :
• Gradual onset
• Little or no discomfort to patient
• Pus discharge associated with sinus tract
RADIOGRAPHIC DIAGNOSIS :
• Large periapical lesion found
TREATMENT :
• Elimination of infection from canal.
• Once Root canal filled,repair of periradicular tissues generally
takes place.
PHOENIX ABSCESS
Acute exacerbation of asymptomatic apical periodontitis
SYMPTOMS :
• Tender on palpation
• As inflammation progresses,tooth gets elevated fron its
socket & becomes sensitive
• Mucosa over periradicular area may appear red & swollen
RADIOGRAPHIC DIAGNOSIS :
• Radiograph shows well defined periradicular radiolucency
TREATMENT :
• Establishing drainage and controlling systemic
reactions
• When symptoms have subsided,tooth is
endodontically treated
• In 1st visit,through debridement by instrumentation
and irrigation before medicating and sealing the canal
• Once canal is sealed, the endodontic treatment is
completed.
CONDENSING OSTEITIS
Localised bony reaction to a low grade inflammatory
stimulus,usually seen at the apex of a tooth in which
there has been long standing pulpal pathosis.
CAUSES :
• Mild irritation from pulpal disease that stimulates
osteoblastic activity in alveolar bone
SYMPTOMS :
• Usually asymptomatic
• Discovered during routine radiographs
RADIOGRAPHIC DIAGNOSIS :
• It shows localised area of radiopacity
surrounding affected root.
• Dense bone with reduced trabecular pattern.
TREATMENT :
• Endodontic treatment is indicated
EXTERNAL ROOT RESORPTION
It is a lytic process occuring in cementum or
cementum & dentin of roots of teeth.
CLASSIFICATION:
1. External surface resorption
2. External inflammatory root resorption
3. External replacement resorption or ankylosis
• SYMPTOMS:
• Asymptomatic
• When root is completely resorbed ,tooth may become mobile.
• If resorption extends to crown,pink tooth appearance seen as
internal resorption.
• in replacement type of resorption ,gradually replaced bone
• RADIOGRAPHIC EXAMINATION:
• Appears as concave or ragged areas on root surface & blunting
of apex.
• In replacement resorption roots are resorbed with no pdl space
• TREATMENT:
• If external resorption is due to extension of pulpal
disease into supporting tissues,ROOT CANAL
THERAPY will stop resorptive process.
• Excessive forces from orthodontic appliances can
be stopped to reduce resorption.
• In case of cervical external root resorption,surgical
exposure &restoration with suitable restorative
material is treatment of choice.
DENTAL CARIES
It is a multifactorial,infectious,microbiologic
disease of teeth that results in localised
dissolution and destruction of the calcified
tissues
DIAGNOSIS
• TRADITIONAL METHODS
Patients complaint
Meticulous clinical examination
Tactile examination
Radiographic examination
Tooth seperation
Dental floss or tape
Fiberoptic transillumination
Patients complaint: It provides a hint about presence of caries.
Meticulous clinical examination: Careful examination of patients teeth
under clean and dry conditions using good illumination may reveal
visual signs of cariesn like brownish discolouration,opacities,frank
cavitation.
Tactile examination: Use of a dental explorer help in detection of
caries
Softness
Binding or catch
Cavitation
Radiographic examination: Conventional,intraoral
periapical,bitewing radiographs are employed
Tooth seperation: Seperation of contacting teeth can be
achieved by wedges or a mechanical seperator to
detect proximal caries
Dental floss or tape: Whenever dental floss is sawed
between teeth,if it frays or shreds then it is a sign of
proximal caries
Fiberoptic transillumination: When teeth are
examined underfiberoptic light source,caries
appears as a darkened shadow as carious
lesions have lowered index of light
transmission
• RECENT METHODS
Xeroradiography
Digital radiographic methods
Computer aided radiographic method
Digital fiberoptic transillumination
Dyes for detection of caries
Alternating current impedance spectroscopy
technique
Ultrasonic imaging
Xeroradiography: The image is recorded on an aluminium plate coated
with a layer of selenium particles.These selenium particles are
charged uniformly and stored in a unit called “conditioner”. When x
rays are passed on to film,it causes selective discharge of particles
which forms the latent image.This is converted into positive image.
Digital radiographic methods: The first direct digital radiographic
sytem in dentistry was the RADIO VISUO GRAPHY introduced in
1989.It uses a charge dcouple device which works like a miniature
video camera.
Computer aided radiographic method : This method uses the
measuring potential of computers in assessing and recording the
size of the carious lesions
Digital fiberoptic transillumination: It is a new
technique which combines fiberoptic
transillumination and a digital CCD camera.Images
captured are sent to a computer for analysis
Dyes for caries detection: various dyes like
Procion,0.5% basic fuschin in propylene glycol are
used to stain the infected,demineralised dentin.
Alternating current impedance spectroscopy
technique (ACIST) : It characterizes the electrical
properties of the tooth and lesion by scanning
multiple frequencies of alternating current
Ultrasonic imaging: Used to detect early caries on
smooth surfaces. An ultrasonic probe is used which
does not produce echoes on normal enamel where as
surface echoes were produced on initial white spot
lesions.
Visual method using international caries detection and assessment
system
ICDAS uses two stage process to record the status of the caries lesion.
The first is a code for restorative status of the tooth and the second is
severity of the caries lesion.
0=sound tooth
1=first visual change in enamel
2=distinct visual change
3=enamel breakdown and no dentin visible
4=dentinal shadow not cavitated
5=distinct cavity with visible dentin
6=extensive cavity
0=not sealed or restored
2=sealant,partial
3=sealant,full;tooth coloured restoration
4=amalgam restoration
5=stainless stell restoration
6=ceramic,gold,PFM
7=lost or broken restoration
8=temporary restoration
After caries detection treatment of caries varies
from sealant,restoration to root canal
treatment,extraction depending on the extent
of caries progression.
Yes likely
Deep caries
Pulp
Size of exposure Step wise
exposed excavation to avoid
Large Small no no exposure
bleeding excessive Preparation deep no Apply pulp
excessivel bleeding protection
y
Yes
and
Indirect pulp capping restore
Pain preoperatively
Yes no
Vital responses
Yes
preoperatively Direct pulp capping
no radiographic
no evidence
periradicular
pathology
