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Dental Tribune Pakistan Edition

By Dr. Thomas Jovicich Pakistan Edition July 20144 DENTAL TRIBUNE he goal of endodontic treatment is for the clinician to achieve an effective cleaning and debridement of the root canal system, including the smear layer and all of its mechanical and bacterial byproducts. Traditionally this is accomplished via mechanical instrumentation in conjunction with chemical irrigants together and actively engaged to completely debride and sterilize the root canal system. The root canal system is a vast and complex threedimensional structure comprising deltas and lateral canals, along with multiple branches off of the main root canal system (Figs. 1, 2, 9). Before the clinician can begin to treat a patient in need of endodontic treatment, he or she first must come up with the proper diagnosis. Once the diagnosis has been made, it then must be integrated with the treatment plan. Taking that treatment plan and presenting it to the patient creates the next challenge: creating value for the patient. One of my most difficult challenges as a working endodontist is creating value for the patient in my chair who has no pain and is here because his or her dentist “saw something” on the radiograph. Pain is the greatest patient motivator we have in dentistry today. The focus of this article is on diagnosis, and it is my goal to provide the reader with a good grasp of diagnosis as it relates to endodontic treatment. Endodontics is all about vision. You have it. I have it. The dentist down the street has it. Doing root canals today is all about having the confidence to make the proper diagnosis. This is achieved through repetition. The more you do it, the easier it becomes. In addition, you need consistency that is achieved through positive reinforcement. Once you believe you can do it and the results support that, you then develop competence. This allows you to retain the skills you have worked hard to hone. The most important trait to utilize in clinical practice today is common sense. This is what separates the true artisans from tooth mechanics. The key component to endodontic treatment is diagnosis. It is based upon using a multifocal approach that involves: patient report, medical and dental history, clinical signs and symptoms, diagnostic testing, radiographic findings, restorability. Taking and collating all of this information will allow the clinician to arrive at a proper and thorough diagnosis. Let’s break these down and delve into what needs to be done. Patient report This is the first opportunity to create a road map to a diagnosis. The goal is to ascertain the nature of the problem. Step one: Ask the patient the where the pain is located. Once you’ve localized the area, it’s imperative to ask a few more questions. The next question should involve determining pulpal vitality through the use of an ice pencil. Other times the patient will volunteer this information with a statement like: “The minute I put anything cold on this tooth, the pain is present and quite intense.” This information suggests that the pain may be pulpal in origin. Because the trigeminal nerve is involved in endodontics, it is important to determine any type of radiating pain. It is not uncommon for maxillary pain to radiate from the mandibular area and vice versa.Afinal area of feedback I want from patients relates to biting and chewing. The patient’s report is the foundation upon which we begin the diagnostic procedure. Asking probing and leading questions in “plain English” will allow the patient to give you critical diagnostic information. Medical and dental history Once you have the patient’s report, probing his or her medical and dental history gives clarity to the background. What are the patient’s medical allergies? What recent dental treatment has the patient had? Was there any mention of restorations placed that were near or at the pulp? Many times a patient will mention having heard the dentist tell his assistant that they were close to the pulp during the excavation of decay. Asking detailed questions enables you to enrich the diagnostic canvas as to why the patient is sitting in your chair. Clinical signs and symptoms By this point, you have listened to the patient’s chief complaint and you have taken radiographs or digital images. It’s time to “test” the patient. The “bite test” involves having the patient attempt to reproduce the pain through biting on an orangewood stick or a cotton swab or a wet cotton roll. If there is pain to bite, you are dealing with some degree of pulpal inflammation with secondary involvement of the periodontal ligament. Once you have this information, the next step is to look at your digital imaging and analyze the relationship of the periodontal ligament (pdl) to the root. Is there a thickening? Is there a widening? If the patient reports pain to bite upon release, this infers that there may be some structural root damage (Figs. 5a & b). At that point is it essential to look at the occlusal surface of the tooth, account for the type and age of any restoration and inquire if any recent dentistry has been done. In addition, it is imperative to probe the suspected tooth. Probing from buccal to lingual with at least four measurements per side is the best barometer to assess periodontal health. If you find an isolated defect in any single probing, you are most likely dealing with a fracture of the root. Endodontic treatment to confirm or rule out a fracture is indicated in these clinical situations. Diagnostic testing The percussion test involves using the blunt end of a mouth mirror or periodontal probe to assess for periodontal inflammation. It is imperative that the clinician gets a frame of reference. This is accomplished by testing the same tooth on the opposite side of the arch. In addition, it is prudent to test the suspected tooth as well as the teeth on either side. Testing should involve both the occlusal and facial surfaces. Thermal tests utilizing hot or cold are the definitive modality to assess pulpal vitality. There are a myriad of ways to test with cold, including CO2 systems, refrigerant sprays and ice cubes (pellets). I believe ice pellets are the best way to test for cold symptoms. In our practice, we use anesthetic carpules that are filled up with water and frozen. This method is cheap, efficient and plentiful. The goal is to reproduce the patient’s symptoms. Many patients who report pulpal hyperemia have managed this symptom by utilizing the opposite side of their mouth. Temperature symptoms are a major motivator for patients to seek dental care. Testing with ice involves establishing a baseline to cold. Typically, I chose to test the same tooth on the opposite side or the maxillary central incisor. I ask patients to tell me when they feel an “electrical shock or jolt” to the tooth. As soon as they do that, I remove the ice from the tooth. This is easily accomplished on the buccal surface of the tooth at the margin of the gingiva. When porcelain restorations are present, I strive to put the ice right at the margin on or above any metal margins. Sometimes it is necessary to apply the ice on the lingual aspect of the tooth. As unresponsive as porcelain restorations can be, the clinician needs to be aware that pulp testing gold restorations can have the opposite effect. This is because of the metallurgical properties of gold. It is an amazing conductor of temperature. Always forewarn the patient when testing gold-restored teeth. Ask the patient if the cold on the tooth reproduced his or her pain. Also, ask if the pain lingered after you removed the ice from the test site. If the pain it is lingering, it is a sign of irreversible pulpitis. In some cases the pain can and does radiate along the pathway of the trigeminal nerve. Sometimes, especially in the maxilla, referred pain can be related to sinus issues, such as sinusitis, allergic rhinitis and rhinovirus. If the patient does not respond to Diagnosis 2014: The things you need to know for successful endodontic treatment This article qualifies for CE credit. To take the CE quiz, log on to www.dtstudyclub.com. Click on ‘CE articles’ and search for this edition of the magazine. If you are not registered with the site, you will be asked to do so before taking the quiz. You may also access the quiz by using the QR code below. rootsce credit Fig.1 Fig.2 Fig.3a Fig.3b Fig.1 Maxillary molar. Note the complex anatomy and multiple portals of exit. (Photos/Provided by Thomas Jovicich, MS, DMD) Fig.2 Mandibular molar. Note the curvature along with the multiple portals of exit. Fig.3a Maxillary central incisor with a periapical lesion. This is a markedly calcified canal. Fig.3b Maxillary central incisor with completed root canal using Sybron TFA rotary nickel titanium instruments, Sealapex sealer. Note the multiple portals of exit in the apical region. T Editor - Online Haseeb Uddin Clinical Study By Dr. Thomas Jovicich

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