Problem Solving in Endodontics

Prevention, Identification and Management

James L. Gutmann, Paul E. Lovdahl

• Publisher: Mosby
• Year: 2010
• ISBN:
  9780323078016
• Edition: 5
• Topic: Medicine
• Subtopic: Dentistry

Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl, offers updated techniques and an evidence-based approach to the most common procedures performed at chairside. Ideal for both endodontists and general dentists, this thoroughly revised reference combines the precision of quality endodontic care with achievable and pain-free outcomes for the patient. Each chapter has been carefully designed so that you'll quickly grasp the anatomy, the instruments needed, and what procedures should be performed-- all supplemented by boxed clinical case examples and tips. Going beyond problem solving, it also addresses the major issues in diagnostic, anatomic, restorative, periodontic, traumatic, and surgical aspects of tooth retention.

• Provides chairside guidance for the endodontic procedures most commonly performed by endodontists and general dentists.
• Entire text has expanded concepts that are verified in new drawings and clinically relevant cases.
• Integrates new technologies and materials into every chapter that when applied result in predictable and optimal outcomes.
• Establishes clear parameters for the retention of teeth.
• Correlates optimal patient outcomes with an evidence-based approach.
• Reflects the practical expertise of renowned endodontics authority and past President of the AAE, Dr. James Gutmann, and endodontics specialist, Dr. Paul Lovdahl.

• Every chapter has been completely rewritten, and concepts have been integrated for quick recognition, understanding and application to common, everyday challenges.
• The Surgery section has been expanded with new case studies, and more in-depth coverage of indications and applications for surgeries, such as crown-lengthening technique, periradicular surgery to manage perforations and resorptive defects, and other endodontically-related problems.
• The approach of this text is to teach the clinician how to recognize and analyze the problems encountered and to synthesize the datafor realistic and successful outcomes.
• To help you make the best clinical decisions, this edition contains new chapters and new sections on diagnosis and treatment planning that presents crucial information on Radiographic Images, Differential Diagnosis of Bony Defects, Diagnosis of Treatment Failure, and Diagnosis of Non-odontogenic Pain.
• Retains a succinct, user-friendly format with a new design that includes hundreds of NEW high-quality clinical photos and art.
• Offers broader coverage of tooth trauma with established treatment planning outcomes.
• ALL references are updated and annotated in the text.
• Provides a practical, problem-solving approach with new chapters on: radiographic technique and interpretation; impact of pulp disease on the periodontium and vice versa; treatment failure and tooth retention; how to differentiate problems of pulp/periodontium from those that are non-odontogenic in nature; vital pulp therapy; and more.

part 1

Problem Solving in Diagnosis and Treatment Planning

Chapter 1 Problem Solving in the Diagnosis of Odontogenic Pain

Problem-Solving List

Problem-solving challenges and dilemmas in diagnosis addressed in this chapter are:

Taking an Accurate Dental History

Interpretation of Historical Data and Subjective Findings

Clinical Examination: Objective Findings

Visual inspection

Use of the explorer

Palpation

Percussion

Bite pressure test

Periodontal probing

Mobility

Radiographic Interpretation

Differential Tentative Diagnosis

Sensibility (Vitality) Testing

Theory

Applicable and Pertinent Testing Techniques

Cold test

Heat test

Dental (rubber) dam application for thermal pulp testing

Electric pulp test

Anesthetic test

Test cavity

Clinical Diagnostic Scheme Based on Test Responses

Normal

Reversible pulpitis

Irreversible pulpitis

Irreversible pulpitis not localized

Necrotic pulp

Aerodontalgia/Barodontalgia

Putting It All Together: the Final Pulpal Diagnosis

“A few moments’ consideration of the original cause of trouble at the apex of roots enables us to realize what is required to be accomplished in the way of successful treatment. If the original cause is admitted to be irritation from decomposing pulp, its removal will in most cases affect a cure.”²⁷

W. Whitehouse, 1884

Making an accurate endodontic diagnosis is a problem for many dentists. The solution to this problem is neither easy nor lends itself to a method that can be reduced to a series of simple steps. A further complication is that most clinicians find it difficult to challenge long-held concepts and practices and resist the notion that these beliefs may be biased. Their experience, under examination, may be limited. There is also a tendency to place trust in authorities without asking how these authorities came to be dominant influences in clinical thinking and practice. When attending a continuing education course, it is not unusual to have thoughts, such as “I already know this,” or “I have heard this before,” or “There is nothing new to be learned here.”

Dentists attend continuing education courses or read professional literature with the intent to improve their knowledge and abilities. In reality, most of the information in a course may not be new to an experienced clinician. What is often missed by clinicians, however, is the importance of detail, relative significance of concepts, and how this unique information can enhance their diagnostic acumen and clinical data gathering. Upon returning to the practice of dentistry, the information presented in the educational experience is often forgotten, and the clinician is destined to repeat the same errors they have been perpetuating for years. In an attempt to minimize this nonproductive process, and in the hope that ingrained patterns of erroneous thinking in the diagnosis of pulpal and periapical pathosis states will be clarified, simplified, and enhanced for the dental clinician, this chapter will provide detailed diagnostic methods used by the authors and most endodontic specialists.

Most concepts may already be familiar; the intent of this chapter is to provide a context for each method or test that will emphasize its unique importance in a problem-solving format. Not all diagnostic tests, examination methods, weighing of historical information, or patient subjective data are relevant to every case. Through clinical examples, the value of each approach will be emphasized to assist the clinician in reevaluating the entire diagnostic process and the incorporation of a realistic and meaningful approach to making a final diagnosis.

Taking an Accurate Dental History

The most common complaint that brings people to the dentist is pain. It is usually an acute problem termed “an emergency” by the patient, who typically characterizes it as being swollen, having pain to biting, being unable to tolerate temperature changes, or the statement, “I have an infection in my tooth.” Occasionally the dental problem is the result of trauma that is usually obvious by appearance; or the patient arrives with complaints of vague or nonlocalized pain. In some cases, pain may not be a reason for the dental consultation at all. The specific nature of the problem is sorted out during the consultation interview, where patient statements and other critical information are collected. In addition to revealing much information about the dental problem, this initial contact, if done in an open and nonthreatening manner, will usually disclose patients’ expectations, previous experiences, fears, and their understanding of the nature of their dental problem.

Because pain is so variable and its perception so subjective, history taking will require gathering and interpreting appropriate information. Patients frequently have strongly held preconceptions that may not be true or relevant. For example, often they believe they know which tooth is causing the problem. The clinician must be able to distinguish information that is useful, such as “I cannot bite on this tooth,” from that which is subjective, such as “The pain hurts me in these three teeth.” It is highly unlikely there are three teeth creating the patient’s problem, but it is quite common for pain to be referred to an area larger than the area of the offending tooth. A few pertinent questions to obtain greater insight into the patient’s specific problem may include:

• “Is there a tooth that is bothering you at this time?”

• “Are you experiencing pain?”

• “How would you rate the pain on a...

Table of contents

• Cover
• Title Page
• Front Matter
• Copyright
• Preface
• Acknowledgments
• Dedication
• New to this Edition
• Table of Contents
• part 1: Problem Solving in Diagnosis and Treatment Planning
• part 2: Problem-Solving Treatment Procedures in Nonsurgical Root Canal Procedures
• part 3: Problem-Solving Treatment Procedures in Surgical Procedures
• part 4: Problem Solving Issues in Adjunctive Dental Procedures
• Index