Ch06: ENDODONTIC DIAGNOSTIC PROCEDURES

Chapter 6 ENDODONTIC DIAGNOSTIC PROCEDURES John I. Ingle, Geoffrey S. Heithersay, Gary R. Hartwell, Albert C. Goerig, F. James Marshall, Robert M. Krasny, Alfred L. Frank, and Cyril Gaum “For I seek the truth by which no man has ever been harmed.” A dentist can develop a number of assets to become –Marcus Aurelius, Meditations VI. 21, 173 AD a successful diagnostician. The most important of these are knowledge, interest, intuition, curiosity, and Before initiating treatment, one must first assemble patience. The successful diagnostician must also have collective information regarding signs, symptoms, and acute senses and the necessary equipment for diagnosis. history. That information is then combined with results from the clinical examination and tests. This Knowledge process is diagnosis. Stated another way, diagnosis is Primarily, a dentist must depend on himself, not the the procedure of accepting a patient, recognizing that laboratory. Therefore, knowledge is the most impor- he has a problem, determining the cause of the prob- tant asset the dentist must possess. This includes famil- lem, and developing a treatment plan that will solve or iarity with all local orofacial causes of pain, as well as alleviate the problem. numerous systemic, neurogenic, and psychological The diagnostician must have a thorough knowl- causes. In addition, the dentist must be aware of the edge of examination procedures—percussion, palpa- many physical, perceptual, emotional, and behavioral tion, probing, and pulp testing; a knowledge of patho- changes brought about by chronic pain. He must know sis and its radiographic and clinical manifestations; that constant overwhelming pain can affect the func- an awareness of the various modalities of treatment; tion of every organ of the body. Chronic pain patients and, above all, a questioning mind. To be added to can develop increased blood pressure, heart rate, kid- these critical skills is the most basic skill of all, listen- ney function, decreased bowel activity, and hormone ing to the patient. levels. They can have many symptoms, such as nausea, Of all of the important diagnostic tools, the art of vomiting, photophobia, tinnitus, and vertigo. The listening is the most underrated. Yet careful and atten- astute clinician gathers knowledge about the patient tive listening establishes patient-dentist rapport, and his problem through a thorough history and an understanding, and trust. Such a relationship also examination. The history and examination include enhances the patient’s reliability as a historian.1 evaluating the physical, emotional, behavioral, and perceptual aspects of the patient’s pain experience. REQUIREMENTS OF A DIAGNOSTICIAN Under knowledge must also be listed the important Diagnosis is a personal and cognitive experience; there- asset of knowing when and where to refer the patient fore, many of the qualities of a good diagnostician are of for additional consultation. This comes with experi- an interpersonal nature and are based on knowledge, ence and the help of physicians, psychologists, and fel- experience, and diagnostic tools. Diagnosing orofacial low dentists who may be depended on to assist in diag- disease is similar to other medical diagnosis. Pulp tests, nosis. Often the patient is referred because examina- radiographs, percussion, palpation, and other tests and tion reveals a problem clearly in the province of the procedures can facilitate the diagnosing of dental/facial neurologist or otolaryngologist. Sometimes the patient disease, just as the electrocardiograph, electroencephalo- is referred because the examiner has exhausted his graph, echocardiograph, computed axial tomographic knowledge and needs help in diagnosis. The recogni- and magnetic resonance imaging scan, and a host of tion of fallibility and limitation—knowing when to yell other radiographs can facilitate medical diagnosis. for help—is also a major asset to the dentist. 204 Endodontics Interest incorrect, quick diagnosis that may result in improper The second important asset possessed by a good diag- treatment, such as reaching for the forceps or removing nostician is interest. The dentist must have a keen a healthy pulp. interest in the patient and his or her problem and must The dentist obviously cannot abandon other patients evidence this interest by handling the patient with to see one person repeatedly. Too frequently, the prob- understanding. If this attitude is not natural to the den- lem patient is asked to return at the end of the day, when tist, he will render the patient and the profession a serv- both dentist and patient are tired and irritable. A better ice by referring all diagnostic problems to an interested solution is to see the patient in the morning, before and competent fellow practitioner. office hours. The dentists who are not willing to assume this imposition, and they are many, are urged to refer Intuition the patient to their more altruistic colleagues. In addition to interest and knowledge, the good diag- Senses nostician is blessed with intuition or “sixth sense,” so to speak. Good diagnosticians intuitively sense the pres- The good diagnostician must have the astuteness to ence of something unusual. This ability, which some- grasp what his senses reveal. First, he has a voice to ask times allows for “instant” diagnosis, is developed questions and ears to hear the answer; he has eyes to see through broad experience with pain problems having and hands to probe and palpate. In short, the dentist unusual and multiple diagnoses. has senses with which to communicate with the sick Intuition tells the dentist when the patient is hold- patient. But, as Friedman pointed out, “One must learn ing back information or is not telling the complete to listen with the third ear and see with the third eye” truth. Moreover, intuition immediately makes the (personal communication, 1972). examiner subtly aware of the patient who “knows too Controlling these senses, however, is the mind, and much,” that is, all of the words and symptoms related to if the mind does not inquire and then reason, or has a certain condition. Intuition allows the dentist to sus- not accumulated the knowledge necessary to inquire pect the unusual, but it also goes hand in hand with still and finally to analyze, then the senses are useless. The another prime asset of a good diagnostician, curiosity. mind must list all of the possible causes of the pain and then, more often than not, eliminate them one by one Curiosity until the correct diagnosis is made. The dentist must pursue or develop a natural curiosity HISTORY about the patient and his condition if perseverance is to be maintained in arriving at a diagnosis. Dr. Harry Anamnesis, “recollection” or “calling to memory,” is the Sicher often likened dental diagnosis to the actions of a first step in developing a diagnosis. The importance of good detective, and curiosity is a detective’s greatest asset obtaining and recording this “history” goes beyond (personal communication, 1954). Medawar described medicolegal protection. A complete history (Table 6-1) diagnosis as the “use of the hypothetico-deductive sys- will not determine treatment but may influence modi- tem.”2 Again, curiosity goes with interest, and the den- fications in endodontic treatment modalities. It will tist who is bored by the painstaking methods of diagno- seldom deny treatment. A complete medical history sis will never have the curiosity to delve a little deeper, should contain, as a baseline, the vital signs; give early probe a little further, or ask the unusual. All of this takes warning of unsuspected general disease; and define time and thus requires patience. risks to the health of the staff as well as identify the risks of treatment to the patient. The medical history Patience must be updated regularly, especially if there have been Often a definitive diagnosis of unusual pain may take any changes in the patient’s health status. hours, days, or even months to develop. Some patients The procedure developed by the American Society complaining of unusual pain may have suffered this of Anesthesiologists is a good system for organizing pain for years, so the dentist cannot expect to make a and assigning risk (Table 6-2). Once the status of the quick diagnosis in a matter of minutes. This is the rea- patient’s general health has been established, a dental son, as stated earlier, why a difficult diagnosis may be diagnosis is best developed by following the time-hon- unrewarding financially but very rewarding emotional- ored formula of determining the chief complaint, ly. Again, if the dentist is not willing to sacrifice the enlarging on this complaint with questions about the time to attempt to help these individuals, he is urged to present dental illness, relating the history of past den- refer the patient for diagnosis rather than make an tal illness to the chief complaint, and combining this Endodontic Diagnostic Procedures 205 Table 6-1 Medical History Form* MEDICAL HISTORY Name ________________________ Sex _______________________________________ Date of Birth __________________________ Address ________________________________________________________________________________________________________ Telephone _________________________________ Height _______________________ Weight _______________________________ Date ________________________ Occupation ________________________________ Marital Status _________________________ MEDICAL HISTORY CIRCLE 1. Are you having pain or discomfort at this time? .......................................................................................................

Load more