Diagnostic Methods and Conduct in Conservative Dentistry/Endodontics
PLAN
- Definitions
- Diagnosis
- Differential diagnosis
- The etiological diagnosis
- Goals
- Different types of exams
- The full review
- The recall exam
- The emergency examination
- The control exam
- Different times of the clinical examination
- Welcoming the patient
- Anamnesis (questioning)
- Civil status
- The reason for the consultation
- The history of the disease
- Medical anamnesis
- Oral exo examination
- Intermediate exam
- Intraoral examination
- Examination of the causal tooth
- Establishing the diagnosis
- Treatment plan
- Prognosis
- Means and methods of clinical investigation for the diagnostic approach in oc/E
- Traditional diagnostic methods
- Visual examination
- The survey
- Separator elastics
- Dyes that reveal caries
- X-ray examination
- Current diagnostic methods
- Digital radiography
- Optical Aids
- The Transillumination
- Single fiber optic transillumination or: FOTI
- Fiber optic trans-illumination with digital imaging or DIFOTI:
- Fluorescence systems
- The DIAGNOdent
- Quantitative laser fluorescence or QLF (Quantitative Light induced Fluorescence)
- Intraoral LED Fluorescence Cameras
- Electrical methods
- Air abrasion
- Ultrasound
- Traditional diagnostic methods
Diagnostic Methods and Conduct in Conservative Dentistry/Endodontics
Introduction
In conservative dentistry, as in all other medical disciplines, it is always necessary to precede treatment by establishing a correct and precise diagnosis based on the integration of the subjective and objective data collected, allowing for comprehensive care of the patient.
1. Definitions
1.1. Diagnosis : is the art and science of identifying any deviation from normality, based on data from questioning and examination.
Identifying an abnormality allows for planning and providing appropriate treatment.
•This is the step that allows the identification of a disease by its symptoms
1.2. Differential diagnosis : is a process during which conditions presenting a partial similarity in their clinical pictures with those that the practitioner seeks to identify are eliminated.
1.3. Etiological diagnosis
A disease can be caused by an iatrogenic or bacterial agent or follow another existing disease that is not or poorly treated. It is then a question of finding the cause of the pathology according to the clinical data collected.
2. Objectives
- Therapeutic,
- Screening and prevention,
- Clinical research
- Archiving and information.
3-Different types of exams
Depending on the circumstances, the dentist can perform four types of examination:
3.1. The complete examination
Includes history, detailed physical examination, required x-rays, laboratory tests, indicated tests, specific diagnoses, a comprehensive treatment plan and prognosis.
3.2. The recall examination
Partial or routine examination, which includes a medical interview and a brief history, an intraoral examination, any X-rays deemed necessary, a precise diagnosis, appropriate treatment and a prognosis.
3.3. Emergency examination
It is first a brief and rapid examination, which consists mainly of an assessment of the problems complained of by the patient. This assessment is guided by the acute and often painful nature of the problem, and it is combined with a brief review of the patient’s state of health and the possible repercussions of this state on the possible treatment.
3.4. The control examination
Consists of looking for changes that have appeared since the last assessment
4. Different times of the clinical examination
This test is recommended for all new patients
4.1. Welcoming the patient
The first contact between the practitioner and the patient is of primary importance in the relationship that each will have throughout the treatment.
4.2. Anamnesis (questioning)
The interview is an important part of the clinical assessment; the anamnesis allows for establishing initial contact with the patient, accumulating information on subjective signs, guiding the clinical examination and making the diagnosis.
4.2.1. Civil status
-Name. -First name.
-Age: to identify the type of dentition (temporary, mixed, mature or immature permanent teeth)
-Sex: pathologies linked to sex
-Place of birth: fluoride level.
-Profession: diagnostic assistance (occupational diseases)
-Address: the social environment and its way of life, for therapeutic conduct.
-Telephone number: for monitoring therapy.
4.2.2. The reason for the consultation
This is either:
-The pain
-Functional discomfort
-Aesthetic disorder
-A unclogging
-A restoration of the oral cavity.
-A periodic visit if the consultation.
Diagnostic Methods and Conduct in Conservative Dentistry/Endodontics
4.2.3. History of the disease
The patient tells the story of his illness in his own words, the practitioner must listen and not direct the patients’ responses, we note:
- Location of symptoms
- The onset and course of symptoms
- Clinical progress:
- Circumstances of onset: start and end of each painful episode (spontaneous, provoked, sudden or progressive)
- Frequency of symptoms
- Duration: should be estimated approximately in terms of seconds, minutes and hours or longer time interval.
- Frequency: specifying whether the symptoms persist without remission since the beginning, or their appearance is intermittent.
- Intensity and severity of perceived symptoms: different methods for assessing the degree of pain intensity:
- Pain Index: The patient is asked to rate the degree of their pain on a scale from 0=complete comfort, to 10=severe or intolerable pain.
- Pain classification: The patient is asked to classify his or her pain into one of 3 categories: mild, moderate, or severe.
4.2.4. Medical anamnesis
This is all the information concerning the general state of health of the patient provided by the patient or by those around him.
- General background
- It is necessary to know whether the patient is in a satisfactory general condition.
- The patient’s physical conditions and medical history may have implications that could alter the usual course of treatment.
- Local history : the patient is asked if he has ever undergone dental treatment such as care, extraction and it is noted if there was a complication to this treatment e.g.: hemorrhage, discomfort, etc.
- Medication history : it is important to know the patient’s current medication in order to avoid any drug interactions that could cause allergic phenomena.
4.3. Exo oral examination : includes two stages
- Inspection : This is the first step of the clinical examination, it is the visual and vigilant observation of the patient in the smallest details. It is the art of seeing and observing, rather than simply looking.
The sound elements
•Facial symmetry
•Appearance and coloring of the integuments
- Palpation : takes place in three stages
•Palpation of the muscles
•Palpation of the lymph node chains
• Palpation of the ATM
Diagnostic Methods and Conduct in Conservative Dentistry/Endodontics
4.4. Interim examination
- Opening amplitude (40 mm) : its limitation will reveal a muscular, articular or dental pathological process.
•It can be temporary: trismus due to defense contractions of inflammatory etiology.
– Most often of dental cause: apical, periodontal, pericoronary infection which disappears with the removal of the causal lesion.
•As it can be permanent: of bone cause, temporomandibular ankylosis, or bone anomalies
- Closure path : we look to see if the mouth is closed in one or two stages
- Examination of occlusion :
- Static examination
•The inter-incisor line: in the ideal case the median lines between the upper and lower incisors coincide. If there is no coincidence we speak of left or right latero-deviation.
•Over jet: covering of the lower incisors by the upper incisors in the horizontal direction.
•Over bite: in the vertical direction, its average value is 2mm.
•Angle Class: canine; molar
• Compensation curves: Spee curve (exaggerated, inverted or disturbed); Wilson curve
- Dynamic examination
•Maximum intercuspation position: this is the position in which there is the maximum contact between the teeth of the two arches.
•Propulsion: anteriorly ideal case 2/4 contact, posteriorly disocclusion on both sides.
•Laterality / diduction: working side 3 possibilities: canine function, group function, or anterolateral = canine + lateral.
4.5. Intraoral examination
- Oral hygiene.
- Soft tissue examination: condition of the gums, condition of the mucous membranes, floor of the mouth, tongue, palate, vestibule
- Hard tissue examination
-The CAD index
– Fractures, Cracks
– Anomalies of shape, position, and number.
– Abraded teeth, loose teeth, condition of restorations
4.6. Examination of the causal tooth
- Subjective signs
– We note the characteristics of the symptoms
-pain provoked or spontaneous
– Triggering factors.
– intensity
– The location.
– the duration
– whether it is calmed by taking painkillers or not
- Objective signs: Objective physical signs or symptoms are detected, which are functional or structural changes
- Visual Signs
– the location.
– the state of disrepair, the loss of substance
– Tooth staining
– The depth
– Content and nature of affected tissues
- In situ signs : includes clinical tests which are:
- Dentin sensitivity test
- The pressure test: this test tells us about the depth of the caries cavity and its proximity to the pulp ceiling. It is carried out by delicately applying a cotton ball held with tweezers to the bottom of the cavity with a certain amount of pressure.
- Percussion test
•Vertical percussion: provides information on the health of the periodontium
•Horizontal percussion: desmodontal alteration, pulp disturbance.
- Tooth mobility test
Pulp sensitivity tests
- Thermal testing
- Cold test
Ethyl chloride: This is a volatile liquid that is sprayed onto a cotton ball, held by tweezers or mounted on a rod, until frost forms. After removing the excess ethylene chloride, it is applied to the neck of the tooth.
Clinical interpretation of results
– Normal pulp: feeling of discomfort or pain, slight to moderate, but temporary.
-Acute reversible pulp inflammation: clear pain with remission when the stimulus disappears.
-Acute irreversible pulp inflammation: sharp pain that persists after the stimulus has disappeared.
-Chronic inflammation or pulp degeneration: feeling of discomfort or very slight pain, but the response is mostly late.
– Pulp necrosis or gangrene: no response.
Diagnostic Methods and Conduct in Conservative Dentistry/Endodontics
- Hot test uses thermoplastic gutta percha
- The electric pulp test
This test is based on the reaction of the pulp tissue to an excitation caused by an electric current, the intensity of which is between 0-200 µA, beyond that, it is the surrounding tissues which react.
- The dentin milling test
It involves gently milling at high speed, to check for vibrations, through the occlusal surface and into the dentin.
Additional examinations
Most of the time the clinical examination will have allowed a diagnostic orientation; but, sometimes, faced with several hypotheses, certain additional examinations must be requested.
•These additional examinations are as follows:
– X-ray examinations carried out at the dental office or by a specialist;
– ultrasound , in the case of certain collections or soft tumors;
– computed tomography (CT) and magnetic resonance imaging (MRI) in certain cases where anatomical measurements must be precise, particularly in their relationships with certain neighboring elements (nerves, cavities, etc.);
– routine laboratory tests (blood count, sedimentation rate, coagulation tests, serological tests, puncture fluid, pus, etc.);
– exploratory puncture , saliva sample;
– the biopsy .
4.7. Establishment of the diagnosis:
•The collection of facts during the anamnesis and the different stages of the clinical examination allow in principle easy identification of the pathology in question and the making of a positive diagnosis.
•But first, it is advisable to make a differential diagnosis before making a positive diagnosis.
•Differential diagnosis
•Positive diagnosis
4.8. Treatment plan:
•once the diagnosis has been made, the practitioner establishes the therapeutic indication, divided into 4 phases:
– general treatment : if the patient has a general illness
– initial treatment : patient motivation for oral hygiene; brushing methods
– Overall treatment : referral to other services if necessary
– Specific treatment : dental therapy following the diagnosis made.
4.9. Prognosis
•Intended to assess the possibilities of healing.
•Several parameters can contribute to this evaluation, in particular:
-Patient motivation.
-Stage of damage to the dental organ.
-Early consultation.
5. Means and methods of clinical investigation for the diagnostic approach in oc/E
5.1. Traditional diagnostic methods
5.1.1. Visual examination: requires
– Good lighting
– Plaque-free dental surfaces
– Dry tooth surfaces
- The criteria used are changes in color, translucency or structure of the enamel, dentin or cement.
The criteria used to assess lesions during clinical inspection are described by Ekstrand et al 1998.
Diagnostic Methods and Conduct in Conservative Dentistry/Endodontics
•The difficulty of access for certain sites, especially at the proximal level where direct examination of this face proves difficult by simple inspection.
•The difficulty of having good lighting in the posterior areas.
5.1. 2. The survey
– It requires the use of exploratory probes (probes 6,9,17 and 23).
– The resistance of enamel to probing is related to the degree of demineralization.
– Probing the occlusal surface can produce irreversible defects.
- This untimely probing method is iatrogenic in the context of preventive dentistry, and is now avoided for the detection of initial lesions, but the technique remains useful for the detection of dentin permeability at the level of advanced cavitary lesions.
5.1.3. Separating elastics
– Carious lesions of the proximal surfaces
– The temporary spacing obtained with these elastics allows direct examination of the proximal dental surfaces
5.1.4. Caries-revealing dyes
– The fluorescence of the dye varies with the degree of mineral loss caused by caries
– Reduced penetration of the dye into the initial lesion
5.1.5. Radiographic examination
– Indispensable, very informative. The X-ray is a complementary examination to the visual examination.
– Studies show that radiography reveals on average twice as many proximal lesions reaching the dentin as simple visual examination.
When reading the image, you must:
•Look for a possible solution of continuity of the image of the enamel contour line.
•Look for the presence of a radiolucent zone at the level of the enamel-dentin junction.
•Observe at the level of the pulp chamber a possible image of reaction, a possible sign of pulp-dentin defense against an attack.
- The study by Hintze et al (1998) established a scale for assessing proximal lesions based on the depth estimated on retrocoronary radiography. This scale consists of five scores:
•Score 0: Absence of radiolucent image (healthy tissues).
•Score 1: Radiolucency affecting the outer half of the enamel.
•Score 2: Radiolucency extending to the inner half of the enamel.
•Score 3: Radiolucency reaching the outer third of the dentin.
•Score 4: Radiolucency extending to the inner two-thirds of the dentin.
Diagnostic Methods and Conduct in Conservative Dentistry/Endodontics
5.2. Current diagnostic methods
5.2.1. Digital radiography
Digital radiography allows better visualization of carious lesions by increasing contrasts, highlighting superficial damage to the enamel as well as a quantitative evaluation of densities by radiometry.
This new method allows:
• A reduction in the dose of ionizing radiation and time saving.
• Better visualization of carious lesions by increasing contrasts.
• ZOOM function
• Easy archiving
But :
•This technique uses sensors that can be uncomfortable for the patient, as well as the cost of the systems is high.
5.2.2. Optical Aids
They improve the diagnosis and performance of the classic visual examination.
These optical aids can be portable equipment such as loupes with a magnification of x2.5 to x8 or heavier equipment such as operating microscopes with a magnification of up to 60
The use of a magnifying glass, which reduces the field of vision, requires optimized lighting. Magnifying glasses can be equipped with front lighting systems.
5.2.3. Transillumination
5.2.3.1. Single fiber optic transillumination or: FOTI
– This technique for detecting carious lesions is based on the fact that the loss of mineral is accompanied by a dispersion of light, this light is created by a halogen and transported by an optical fiber by trans-illumination or by the projection of a tungsten lamp on the tooth.
– Lesions are diagnosed by the appearance of spots or shadows.
5.2.3.2. Trans-illumination by optical fiber with digital imaging or DIFOTI:
– DIFOTI emits, like FOTI, a white light through the tooth, which is captured by the CCD camera and sent to the computer.
– The images of the tooth acquired by the camera are sent to the computer which will analyze them using a specific algorithm.
5.2.4. Fluorescence systems
5.2.4.1. The DIAGNOdent
– Device that quantitatively measures mineral loss using a laser emission which in return measures the fluorescence of bacterial derivatives included in infected dentin.
– Emits a wavelength of 655nm;
– Gives a value from 0 to 99 indicating the degree of demineralization of the inspected surface.
Benefits
•an atraumatic method/classic examination.
•demonstrates high reliability and reproducibility of the measurements carried out.
•allows to differentiate the lesions to be treated from those to be monitored.
•a higher sensitivity than radiography in the detection of early caries (radiations).
Disadvantages
•Sometimes doubtful values given (dental plaque, etc.).
•Does not work across restores.
• It cannot assess the quality of caries curettage during a preparation.
•High cost
Diagnostic Methods and Conduct in Conservative Dentistry/Endodontics
- The DIAGNOdentpen
= This is based on the same operating principle, but differs from DIAGNOdent® in its superior handling, it does not have a wire.
5.2.4.2. Quantitative laser fluorescence or QLF (Quantitative Light induced Fluorescence)
– This system consists of illuminating the tooth with a blue light and via a filter, the return image is analyzed in fluorescence value. Software provides information on the surface, depth and volume of the lesion.
– Healthy enamel fluoresces yellow while demineralized areas appear dark.
5.2.4.3. Fluorescence intraoral LED cameras
It consists of an endo-oral camera connected to a computer via a USB port.
- LED cameras, Fluo LED Sopro-Life
-Two types of LED: 1st with white light and 2nd with blue light (450 nm).
-Healthy tissues appear green (blue for areas with thick enamel) and decayed tissues appear light to very dark red.
-The camera operates in three modes: Daylight, Diagnostic and Treatment
- The Vista Proof camera.
-The principle is based on the analysis of bacterial and dental fluorescence when a specific light is applied (blue-violet, wavelength 405 nm).
-This device has been recently improved: VistaCam iX® Proof
5.2.5. Electrical methods
– Teeth have low electrical conductivity due to the presence of enamel .
– When the enamel volume is reduced (hypo or demineralization) this is accompanied by an increase in electrical conductivity (Huysmans et al., 1998).
– Thus, the principle of this technique would be based on the detection of the increase in electrical conductivity
– This increase in conductivity is due to the presence of demineralization microcavities blocked by saliva which plays the role of electrolyte allowing the transmission of electric current.
– The measured site must be cleaned and dried, A conductive gel is deposited on the groove to be measured. Then electrical measurements are made by applying the probe to the gel.
– The devices currently used in dental practice are the CariScan pro®
5.2.6. Air abrasion
– This technique was introduced for the diagnosis of early carious lesions in pits and fissures.
– Wet air abrasion can be used advantageously for diagnostic purposes: under the jet of aluminum oxide (driven by kinetic energy), only the prisms of demineralized enamel collapse.
5.2.7. Ultrasound
-This technique was introduced for the diagnosis of early carious lesions in pits and fissures.
-Every tissue has an acoustic impedance that characterizes its internal sound pattern. Thus, any change in this sound pattern can be correlated with a pathological change in that tissue.
This process is based on a beam of high-frequency ultrasonic waves directed towards the tooth. They will be collected when they are reflected.
The presence or absence of a carious lesion will depend on the dispersion of the waves. (Reference curve).
Diagnostic Methods and Conduct in Conservative Dentistry/Endodontics
Untreated cavities can reach the nerve of the tooth.
Porcelain veneers restore a bright smile.
Misaligned teeth can cause headaches.
Preventative dental care avoids costly treatments.
Baby teeth serve as a guide for permanent teeth.
Fluoride mouthwash strengthens tooth enamel.
An annual checkup helps monitor oral health.