Endodontic diagnosis . Lecture on endodontic diagnostic technique
Anamnesis Case history Clinical examination Radiographic examination
In: Souza et al. Diagnostic concordance in endodontics in dental clinics RGO, vol.59 no.3 Porto Alegre Jul./Sept. 2011
Introduction
Diagnosis can be conceptualized as knowledge of a morbid state obtained through careful and judicious data collection, a procedure that begins with anamnesis, which represents the subjective part of the examination to obtain information that can help define the diagnosis. Silva et al. stated that in the case of alterations to the human dental pulp, the information needed to establish its pathological condition is restricted to anamnesis, clinical examination, pulp sensitivity tests and radiographic evaluation.
According to Ruiz, the clinical examination includes objective data collected by the professional through tests such as palpation, percussion, inspection and exploration. Palpation, based on touch and compression or digital grasping, provides impressions of a given area and can define shape, limits, consistency, changes in texture, thickness, sensitivity, volume, mobility, content, fluctuation, temperature and elasticity. With regard to the percussion test, it does not provide an indication of the integrity of the pulp tissue, but it is important for assessing the degree of involvement of the periapical tissues and whether there is inflammation in the periodontal tissue, thus helping to diagnose periapical and/or periodontal pathologies through vertical or horizontal dental percussion, respectively.
Estrela said that inspection includes visual observation, physical inspection and extra- and intra-oral examination of soft tissues, which determine various aspects of tissue conditions and the condition of dental structures, and are fundamental aspects to be analyzed, just as exploration is a sequence of inspection, in which the presence of dental cavities, periodontal pockets, fistulous tracts, coronary and root fractures are observed. Pulp vitality (sensitivity) tests are used as supplementary resources to the physical examination to establish a differential diagnosis of odontalgia and to assess the vitality or otherwise of the dental pulp in various circumstances. Although they provide subjective answers, they are a great resource in determining a correct diagnosis. Among the tests commonly used are those carried out using thermal stimulation of the surface of the tooth to be investigated. As well as being easy to perform, they are reliable and inexpensive to carry out, and also allow the irreversibility of the pulp to be determined.
The most widely accepted test for determining pulp vitality is the one carried out by cooling the tooth surface. There are different ways of producing this effect, such as using an ice stick, carbonic snow and refrigerant gases. According to Cohen, the pain produced by thermal stimuli, heat or cold, is one of the most common symptoms present in cases of pulpitis. When there is reversible pulp involvement, the painful response to cold is more intense and disappears as soon as the stimulus is removed.
If there is a positive response to the heat test and the pain persists after the stimulus is removed, the pulp is irreversibly inflamed. If there is no response, necrosis may have already set in. Radiographic examination, when properly associated with the patient's clinical examination, helps to locate and identify the problem reported by the patient, thus obtaining a diagnosis and guidance for proper planning and treatment.
According to Ruiz, the clinical examination can diagnose two pulp conditions, reversible and irreversible pulpitis, which have different treatments and prognoses. Reversible pulpitis is by definition a mild inflammatory alteration of the pulp, in the initial phase, in which tissue repair occurs once the triggering agent has been removed. If the irritants persist or increase, pulp inflammation becomes moderate to severe, which characterizes irreversible pulpitis, with subsequent pulp necrosis.
Regarding the diagnosis of reversible pulpitis, Lopes & Siqueira Junior reported that it is usually asymptomatic, but when semiotechnical resources are applied, the patient may feel acute, rapid, localized and fleeting pain, which ceases after the stimulus is removed. In thermal tests with heat, the patient feels pain after the initial application of the stimulus and radiographic examination reveals the presence of carious lesions or extensive restorations close to the pulp chamber.
Endodontic diagnosis
