endodontic diagnosis

ENDODONTICDIAGNOSISDeepthi P.R.1st year MDSDept of Conservative Dentistry & Endodontics

CONTENTS Introduction Diagnosis Diagnostic method Medical history Drugs & medication history Dental history Subjective symptoms Clinical observations Clinical tests

Introduction Thorough knowledge of other sciences Diagnosis & Treatment planning Pain of non odontogenic origin Accurate database: Medical & dental history Clinical examination & relevant tests Making & interpreting appropriate

radiographs

Diagnosis ‘The art and science of detecting

deviations from health and the cause and nature thereof’

Differential diagnosis: ‘The process of identifying a condition by comparing the symptoms of all (or other) pathologic process that may produce signs and symptoms ’

Glossary of endodontic terms. 7th ed. Chicago: American Association of Endodontists;2003

Diagnosis Inability to test/ image the tissue

directly Indirect interpretation of response to

stimuli Determine teeth free of disease rather

than diseased

Newton et al. JOE- Volume 35, Number 12, December 2009

Diagnostic method

METHODSPulp testing

PalpationPercussion

DIAGNOSTIC APPROACHESBite test

Test cavityStaining/ Transillumination

Selective anesthesiaRadiography

Dental history/ Medical history

Evaluation of pain signs/ symptoms

Newton et al. JOE- Volume 35, Number 12, December 2009

Surgical Sieve

Pitt Ford & Rhodes. Endodontics- Problem solving in Clinical Practice

• Biographical details

• Medical history• Chief complaint• History of present

complaint• Dental history• Social history

• Extraoral examination

• Intraoral examination

• Special tests• Radiographs• Diagnosis• Treatment plan

s

A sample form used in diagnosis and treatment planning. (Adapted from Krell K, Walton R: Odontalgia: diagnosing pulpal, periapical, and periodontal pain. In Clark J, editor: Clinical dentistry, Philadelphia, 1987, Harper & Row.)

Medical history Treatment: harmonious with general

health Impact of the patient’s health on the

dental operating team Alterations in the usual course of

treatment Name & contact of physician

Rheumatic fever Potential for SBE after bacteremia

Antibiotic premedication:

Artificial heart valves: Same antibiotic coverage: rheumatic fever

Pulp extirpation

Filing beyond the

apexRubber dam placement

Initial appointment/Surgical appointment

Possibilty of going past the apex

Periapical lesion

Coronary Artery disease Physician consultation: anticoagulant Non surgical treatment preferred Mild / moderate analgesics Brief recess: more than one tooth- single

appointment Substernal pain: dressing placed &

treatment terminated; referred to physician

Hypertension Injection of L/A solutions < 30sec/ml Warm anesthetic solutions: few minutes

before injection Tranquil mood created- minimal mention

of complications & failures Hypnotic premedication: consultation

with physician

Hypertension Avoid G/A & no more than 3 anesthetic

carpules Morning appointments preferred Night time premedication with early

appointments Total appointment time not > 1 hour Terminate when patient is stressed

Diabetes Retarded healing: postop radiographs

Antibiotics: Infection/ surgery 1yearPre op 6

months2 years

1.5 years

3 years

Diabetes Alteration in blood glucose levels:

physician consultation

Epinephrine avoided: Increase in blood glucose levels & tissue sloughs post surgery

Levonordefrin Barbiturates & sedatives cautiously

used

Diabetes Longer & deeper anesthesia L/A preferred

Appointments: soon after meals Differentiate & manage hypoglycemia/

hypoinsulinism

• Mepivacaine +Levonordefrin

• Propoxyphene+ Procaine +Levarterenol bitartarate

Hepatitis Resistant to normal sterilization Intracanal instruments: discarded after

use Avoid drugs detoxified in the liver:

Halothane,Erythromycin Cautious- Paracetamol

Blood diseases Internal bleeding: L/A administration Avoid injections: necrotic pulp Vital pulp:

First appt.• Access to the cavity

• Dressing

Second appt• A week later• Fixed pulpal

tissue removed

• Dressing replaced

Process continued: vital tissue removedCanals enlarged & filled

Blood diseases Rubber dam: Notches- labial & lingual

surfaces Gingival bleeding: do not treatment

without systemic diagnosis Infectious mononucleosis:

Avoided in acute stage

• Pain• Exacerbations• Exaggerated

response to drugs

Joint replacement prostheses Bacteremia Antibiotic

coverage Painful joint after

procedure: orthopedic surgeon consulted

Longer than usual: desirable results

Hypersensitivity states: drugs only when absolutely indicated

Avoid new/ unusual drugs

HIV: transmission avoided- proper asepsis

Other serious Diseases

Recent change in weightWeight loss Dieting Loss of appetite Systemic diseases

Weight gain Psychogenic reasons Hormonal

disturbances Pregnancy Protect exposed

tooth surfaces after endodontic therapy

Salt & water retention

Psychologic problems Physical problems: tendency towards

anxiety Patients on Tranquilizers/

antidepressantsConverted a psychologic condition to

physical problem

Severe fears & anxieties –

treatment difficult

• No relief with treatment

• Pulpal problem suspected: suspicious oral conditions

• Friendly and firm• Instruments: out of

sight• Informative booklets• Smooth & painless

initial visit

Others Hyperthyrodism No epinephrine Increase sedative if neededUlcers Avoid aspirin & if on antacids- avoid

tetracycline Use Penicillin V if neededAlcoholic Cautious with sedatives Aspirin avoided

Drugs & Medication therapy Physical condition & effects of

medications Adverse reactions Questionnaire format Unaware of Drug’s contents : Mosby’s

Drug Consult/ physician History of allergy: minimum inter

appointment time & well monitored

Drugs & Medication therapy Steroid therapy: intratreatment pain &

exacerbations , infections Appointments: maximum 3 days apart Vital: 2 sitting & Necrotic: 3 sitting – 1

week period Surgery- Antibiotic therapy & steroid

dose

Drugs & Medication therapy Aspirin: bleeding after surgery Avoid- Blood dyscrasia, anticoagulant,

renal transplant, gout Caution- Asthma, Diabetes, Last month

of pregnancy Tranquilizer therapy: unusual reactions

to prescribed hypnotics/ narcotics Physician consulted

Drugs & Medication therapy• CNS

stimulant: increase

sedative dose• Sulfonamid

es: avoid procaine

Antidepressants:

Cautious• GA

• Narcotics• Antisialagogue

Tetracycline:• Antacids• Penicillin

Barbiturates : cautious • Dilantin

• Griseofulvin• Steroids

Dental history Patient’s objective for treatment- clear

Appreciation for dental treatment Experiences with previous dentist

Pain relief Check

up

Oral systemic relation

Cosmetics Masticatory inefficiency

Dental history Chief complaint & its history When was it last restored? Pulp capping/ Pulpotomy/ large

restoration in the same Sharp blow/ accident Swelling/ gum boil Drainage

Subjective symptoms Is the pain still present? What type? (Sharp/ dull) Throbbing? Intermittent/ Continuous? Aggravated by: cold, heat, pressure,

mastication, lying down, sweet, sour? How long does it last?

Clinical Observations Extraoral swelling Lymph node

involvement Intraoral

involvement Fistula Tooth discoloration Traumatic injuries:

fractures

Deep carious lesion Recurrent caries

beneath a restoration

Extensive restoration

Developmental defects of teeth

Gingival recession

Clinical TestsDiagnostic tests:1. EPT2. Thermal tests3. Percussion4. Palpation5. Mobility6. Periodontal

evaluation7. Occlusal evaluation8. Radiograph

Selective tests for Difficult Diagnostic Situations:9. Test cavity preparation10. Anesthetic test11. Transillumination12. Biting13.Staining14. Gutta percha point tracing with radiograph

Extraoral examination External facial form & features Fistulae, erythema, pallor Neurologic examination: motor

function, sensitivity, movement Lymph nodes: inflammatory,

infectious, tumor like disorders

Intraoral examinationSoft tissue examination: Swelling/ fistula

Intraoral examination Crown discoloration: non vital pulp,

removal of discolored dentin, use of chlorinated soda

Deep carious lesions/ fractures: visual examination & probing

Percussion test Simple, but useful Inflammatory condition of the apical

periodontium First clinical indications of apical

periodontitis

Percussion test Symptomatic apical periodontitis: more

sensitive Pulpal diseases: not reveled unless

apical periodontium is involved Periodontal/ endodontic etiology,

occlusal trauma, combination with marginal periodontitis

Horizontal percussion

Percussion test Firm digital pressure/ handle of

instrument like mouth mirror: tap in a vertical direction

Patient bite on Tooth Slooth/ Cotton swab

Several teeth repeatedly Random order

Palpation Vestibular region: apical region of the

root tips Tenderness, swelling, fluctuation,

hardness, crepitation Tip of index finger Usefulness increase with skill & clinical experience

Mobility Moving in a buccal- lingual direction Index finger on the lingual surface &

lateral force applied with instrument handle from buccal surface

Using two fingers

Mobility Miller’s index: Class 1- First distinguishable sign of

greater- than- normal movement Class 2- Movement of the crown as much

as 1mm in any direction Class 3- Movement of the crown more

than 1 mm in any direction and/or vertical depression/ rotation of the crown in its socket

Periodontal probing Endodontic & periodontic lesions mimic

each other concurrently Record probing depths: periodontal

health & prognosis Entire circumference probed

Periodontal probingNarrow isolated probing defects: Periodontal disease Sinus- like trap following periapical

pathosis Vertical groove defect Cracked teeth Vertical root fractures External root resorption

Tests for Cracked Tooth SyndromeTransillumination Fiberoptic light Coronal cracks/ vertical root fractures Minimal background lighting Light placed on varied surfaces of

coronal tooth structure/ root after flap refection

Transillumination Light traverses fracture lines- visually detected

Fractured Segment near the light appears brighter

Dye staining Dye penetrates fracture line Demonstrates fractures Apply – internal surfaces of cavity

preparation/ access opening Leave it in place for a week Iodine/ methylene blue dye

Dye staining3 methods:Remove restoration: Direct revealing of fracture line Dye incorporated into ZOE mixture & placed Patient chews on disclosing tablet

Bessner & Ferrigno. Practical guide to Endodontics

Bite test Wooden stick- opposing teeth Tooth slooth Patient bites down & pain elicited upon release Rubber dam sheet- cracked cusp flexes

Pulp tests Major & essential part of diagnostic

process

Reproduce patients symptoms, diagnose diseased tooth & disease

2 independent diagnostic test results

Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010

Pulp tests *Ideal technique: non invasive,

painless, standardized, reproducible, reliable, inexpensive, easily completed & objective

*Chambers. 1982

Pulp sensibility tests

• Thermal tests• Electric pup tests

• Test cavity

Pulp vitality tests• Laser doppler flowmetry

• Pulse oximetry• Tooth temperature

measurement

Pulp sensibility tests Pulp nerve fibers respond – external

stimulus Thermal/ Electrical / Direct dentine

stimulation Do not indicate the health status &

unreliable responses


Pulp sensibility tests No indication of vitality: intact

vasculature Correlation between test results &

necrotic pulps only* Assess whether necrotic or not & does

not quantify the degree of disease Useful : identifying diseased tooth

*Seltzer et al.1963, Tyldesley & Mumford 1970, Dummer et al, 1980

Pulp sensibility testsPreferred sequence:

Tests repeated after 1’ recovery time Thermal tests: no method to assess how

responsive the tooth is or to compare with previous result

EPT: numerical display- not essentially reproducible

Disease free contralatera

l teethOpposing

teeth

Presumably healthy

teeth- same quadrant

Most suspicious

tooth

Rationale of the tests Sharp, non lingering pain- application of

thermal stimulation: normal

A- 25% stimulus required to activate C fibers*

*Virtanen 1985, Hargreaves & Goodis 2002

Thermal tests- Rationale Sensory response: not by temperature

changes in receptors Hydrodynamic movement of fluid:

dentinal tubules- A fibers Cold- faster A fibers: sharp localized

pain Heat- slower C fibers: dull long lasting

pain


Electric Pulp Test - Rationale Current sufficient to overcome the

resistance of enamel & dentine- stimulate A fibers

Sensation felt with gradually increasing level of current: pulp responsive/ partially alive

*Ionic shift in tubules local depolarization action potential

Pantera et al. 1993

EPT- Rationale A fibers: brief sharp sensation/ tingling

*No blood flow- pulp becomes anoxic & A fibers cease to function

*Pitt Ford & Patel 2004

Indications 1.Pain in the trigeminal area; referred pain2. Periodical monitoring of teeth after trauma 1-8 weeks lapse before normal response EPT: reliable after trauma**

*No response Response : RecoveryRepetitious response :Healthy pulpResponse No response: DegenerationNo response persistent: Necrotic pulp

**Ingle et al 2002,*Bhaskar & Rappaport 1973

Indications 3. Assessment of pulpal health before restorative procedures potential prosthetic abutment4. Pulp preservation procedures & extensive restorations5. Differentiate periapical radiolucencies from normal anatomical structures & non odontogenic lesions


Indications 6. Predict potential anesthetic problems & evaluation of analgesics Cold test: assess pulpal anesthesia Preoperative pulp-test performed Traditional parameters verified Retested with the same test Prepared for treatment & level of

anesthesia screened Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010

7. Pulp status of transplanted teeth

Indications 8. Le Fort type fractures/ osteotomies Normal: 7-11 months after surgery

Limitations 1. Subjective; measure only nerve supply2. Thermal tests: not effective in substantial secondary dentine formation3. Unreliability of tests: Immature apices, traumatic injuries, more subjectivity in the young4. No correlation with the histologic status (Contrasting results: Hill, 1986)


Limitations 5. Difficult to administer & inconclusive in children6. Weaker response- aged pulp7. Extensive restorations, pulp recession, pulp calcification8. Lack of reproducibility


Interpretation- Diagnosis Immediacy, intensity & duration of

response Outcome: never certain No particular response- unique to

specific pathologic states


Clinically Normal pulp Mild to moderate transient response to

cold & electrical stimuli Response subsides in few seconds on

removal of stimulus Do not usually respond to heat tests

Reversible pulpitis Thermal stimuli (cold)- sharp pain Subsides as soon as the stimulus is

removed/ in few seconds

Irreversible pulpitis Thermal changes (cold): sharp pain ,

dull prolonged ache- last upto an hour or so

Valuable: stimulus as reported by patient applied & pain reproduced & assessed

EPT: not of value

Pulp necrosis Histological state not determined Significant relation between lack of

response & pulp necrosis No response with EPTs & thermal tests No indication of infection expected from

these

Pulp necrobiosis Difficult to diagnose History : pulpitis Pulp tests: necrosis Vague response to EPTs, cold tests

Periapical conditionsAcute apical periodontitis Maybe associated with pulpitis Pulp status assessed before treatmentAcute apical abscess Negative Lateral periodontal abscess Positive Chronic apical periodontitis Sequel of infected canal system

False responsesFalse negative results: Normal pulps that do not respond to tests Calcification: no response to cold; may

respond to high value of current in EPT Premedication Recent trauma Immature apex RCT teeth: not expected to respond


False responses Extensive restorations Pulp protecting bases High pain threshold Activation of fixed orthodontic

appliances Psychotic disorders Defective EPT device/ discharged

batteries/ poor electrical contact

False responsesFalse positive results: Necrotic pulps responding to tests Conduction of current to adjacent

gingival & periodontal tissues (avoided with reasonable current strength & proper techniques)

Moist gangrene, partially necrotic tissue, infected pulp

Breakdown products of localized necrosis

False responses Calcified tooth structure conducting to

tissue apical to an area of necrosis Current conducted to adjacent teeth

through metallic restorations (avoided by rubber dam / celluloid strips between teeth)

Inflamed pulp tissue in one canal of a multirooted teeth with other canals & chamber necrotic

Anxious/ young patient

False responses More common with EPT than cold test EPTs: all teeth; cold tests: multirooted

teeth EPT: rare false negative, if more than

one surface used Cold test: sometimes, only cervical area

responds

Value of diagnostic tests Precision: ‘Tendency of repeated

measurements on the same sample to yield the same result’

Variability: Lack of precision Accuracy: The extent to which a test

correctly classifies patient’s response Sensitivity: The ability of the test to

detect the disease in patients who actually have the disease


Value of diagnostic tests Specificity: The ability of a test to

detect the absence of a result Positive predictive value: The

probability that a positive test result actually represents a disease positive tooth

Negative predictive value: The probability that a tooth with a negative test result is actually free from the disease

Value of diagnostic tests Heat: relatively high sensibility; but

least accurate being the least specific Cold test: more accurate than EPT

Thermal tests Often inappropriately referred to as

‘Vitality tests’ More reliable than EPT Inexpensive & easy-to- use equipment Patient’s pain reproduced

Thermal tests• Initial cold sensitivity

• Heat sensitivity- continued pulp deterioration

• Disappearance of cold sensitivity

• Cold stimuli might relieve heat induced pain

Damage to hard & soft tissues of the tooth Heat test: more potential to injure Tissue freezing: -100c for 5-20’ Intracellular ice crystal formation &

ischemic necrosis following vascular injuries

-220c lowered pulp temperature to 110c: caused no damage (Langeland et al, 1969)

Damage to hard & soft tissues of the tooth Conflicting reports: Dry ice inducing

enamel cracks Delayed cold transfer process: Cold

stimulus applied to necrotic pulps under a bridge- felt by adjacent tooth

‘Film boiling’/ ‘ Leidenfrost phenomenon’: Insulating layer of CO2 gas around dry ice, if it falls into mouth

Cold testsIce sticks 0oC temperature Not accurate: adult posterior teeth Secondary/ reparative dentin deposition Testing under crowns/ splints Application- 5s : reliable & valid Disadvantage: less effective

stimulation


Cold tests Freezing water- hypodermic needles’

plastic cover/ L/A cartridges Held using gauze Cervical (Ruddle 2002),or middle (Cohen

& Hargreaves 2006),exposed metal surface

Quickly move back & forth

Cold tests Begin with most posterior tooth Cotton pellet placed just distal to the

tooth Contact with adjacent gingiva or nearby

teeth: false responses

Cold testsRefrigerant sprays Convenient & easiest to use Ranks just behind dry ice Dichlorodifluoromethane (DDM) Tetrafluoroethane (TFE) Propane butane mixture (PBM) -20oC to -50oC

Cold tests DDM: Freon-12 Compressed spray: Endo-Ice (-50oC) DDM- production prohibited due to

environmental concerns Greater decrease in temperature than

dry ice & ethyl chloride Saturated cotton pellet: Multiple teeth : less effeicienty tested

Cold tests TFE: Green Endo-Ice (-26oC) No ozone depletion potenial Easy to use & rapid results Sprayed onto cotton pellet & applied to

middle third facial surface 5s or until pain Equivalent to dry ice & even in restored

teeth

Cold tests PBM- Endo-Frost (-50oC) 30-50% Propane, 30-50% butane & 30-

50% isobutane Nontoxic cold spray- freeze cotton

pellets & rolla Similar intrapulpal temperature

decrease

Cold testsCarbon di oxide snow/ Dry Ice Charles Thilorier -1835 Dentistry: Back -1936 Apparatus modified by Obwegser &

Steinhauser 1963: pencil like form -78oC; -56oC direct application Rapid response: <2 s


Cold testsMechanism: PDJ temperature reduced to <2oC Hydrodynamic theory Enamel expansion / contraction & acts

as temperature transfer medium (Linsuwanont et al 2007)

Cold testsTechnique CO2 released into special tube inside

plexiglass container: snow Compacted with a plugger: pencil/ stick Middle third of the facial surface of

crown: 2-5seconds or until pain

Cold testsAdvantages Accurate, reliable, consistent, fast &

uncomplicated 1-2 minutes- without isolation Does not affect adjacent teeth Intense reproducible response Greater accuracy than EPT

Cold tests Full coverage restorations More reliable after trauma Under splinted abutments No false positive in necrosis Sustained lingering response: early

puplpitis Fixed orthodontic treatment

Cold testsDisadvantages Not effective with calcified pulps More expensive than ethyl chloride/ ice

sticks More dependable results than ethyl

chloride/ ice (Fuss et al 1986, Andreasen 1976)

Cold testsEthyl chloride spray Chloroethane (-12.3oC) Colorless, flammable gas Skin refrigerant, mild topical anesthetic CNS depressant Better than EPTs & heated GP Not used: less effective than dry ice/

DDM


Cold tests

Cold water bath Tooth/ group of teeth : isolated with

rubber dam Iced water syringed onto tooth Effective: simultaneous bathing of entire

crown Effective with full coverage restorations Better than ice sticks & no

armamentarium than rubber dam Time consuming

Heat tests Heat: fluid expansion- A fibers Inflamed pulp: C-fibers; lasting response Acutely inflamed/ partially necrotic pulp Low diagnostic accuracy- not used as

single method

Heat testsHeated GP ( Grossman’s method) Warmed sticks of GP (120-140oC) Dry tooth surfaces & surrounding areas

with cotton rolls Iight coating of petroleum jelly GP stick warmed over flame till glistening


Heat tests Difficult to control temperature Concerns of damage to healthy pulp :

not with <5 s application (Rickoff et al 1988)

Reproducible results not obtained Lack of response in bulkier teeth Less consistent stimulus Limited value: posterior teeth & under

splints , temporary crowns

Heat testsWarmed hand instruments Popular, not very reliable & poorly

assessed method Heated over a flame, held close to

buccal surface; without actually touching

Not reproducible Difficult to control temperature & safety

problems

Heat testsElectrical heat sources Touch ‘N Heat/ System B- 150oC Inserts: Hot Pup Test Tip Continuous heat mode- intensity set Tooth surface lubricated

Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010Castelucci. Endodontics Vol.1

Heat testsFrictional heat Rubber cup- prophylaxis Buccal surface Best, easiest & safest Gold crown Seldom used today

Heat testsHot water bath Similar to cold water bath Temperature gradually increased Begin with most posterior and proceed

until positive response Greater thermal change PFM crowns Time consuming & patient cooperation

Remember.. Inform patient of the nature of tests Hand signals Stimulus removed after 5-6 s Refractory period after cold test Cervical aspect (Petyers eta 1994,

Ruddle 2002) middle third of buccal/ palatal aspect

(Cohen & Hargreaves 2006)

Incisal- anterior & incisal aspect of mesiobuccal cusp: posterior (Trope & Debelian 2005)

Ideally be tested on all surfaces Several adjacent, contralateral &

opposing teeth tested Individual perception Should not bias

Electrical pulp tests Direct stimulation of pulp nerve fibers Unreliable: necrotic & disintegrating pulp

tissue leaves electrolytes in pulp space Adequate stimulation, appropriate

technique, careful interpretation AC or DC; Pulsating DC: 5-15ms best

nerve stimulation Rate of current increase, strength

duration & frequency

Electrical pulp tests Benchtop style digital EPT Handheld style digital style EPT Handheld style analog EPT

EPT Monopolar/ Unipolar and Bipolar Mains power connection & Batteries Mid-1950’s: Bipolar- one electrode to the

other through tooth or one handheld Monopolar: anode on the lip & cathode

on the tooth Comparative studies: conflicting results

EPT & Histology No correlation between positive EPT &

histological status* Presence of sensory fibers that can

respond to electrical stimulus Quantification or comparison of

responses- not conclusive Cannot assess vitality Negative response- necrosis

Reynolds 1966, Mumford 1967b, Matthews et al 1974b, Cooley & Robinson 1980

Technique of use Technique sensitive Removal of supragingival calculus Exterior surface dried & rubber dam

placed Insulation of proximal restorations Probe checked on skin- ensure current

flow

Circuit completed Electrode coated with suitable medium Middle third of facial surface Direct contact necessary: small tip on

restored teeth Rheostat: 1-10, 1-15, 1-80 Slowly increased: more accurate

Procedure explained Tingling/ warm/stinging/ full/hot Shift tip position: if no response Tested 2 0r 3 times: ensure consistency Testing switched off / changing order;

eliminates bias & anxiety driven responses

Full porcelain/ gold crowns Cavity prepared through restoration

without L/A until dentin If no response: EPT probe on dentin Rubber dam piece: insulate tip from

metal Highly different response: control tooth

Circuit completion Use without rubber gloves Lip clip: lose retentiveness & reliable

contact Touch the probe handle with finger:

gives patient control Modify EPT with metal rod

Roll down dentist’s gloves: contact with wrist & patient’s face

Custom made patient held contact device

Stabilization groove cut on the probe engaged by current conducting sleeve: not recommended

Variations in reading/ False responseFailure to complete the circuit Equipment

problems Probe placement Interface media

Patient related factors Tooth characteristics Restored teeth Dentition Supporting tissues Apex maturation Repeated trials Psychological state Physiological state

False positive response Necrotic pulp responds to testing. Stimulation of adjacent teeth/

attachment apparatus The response of vital tissue in

multirooted tooth with pulp necrosis in one or more canals

Patient interpretation: subjectivity

William T. Johnson. Colour Atlas of Endodontics

False negative response Vital pulp that does not respond to

stimulation Inadequate contact with the stimulus Tooth calcification Immature apical development Traumatic injury Subjective nature of the tests Elderly patients – regressive neural changes Analgesics for pain Traumatic injury

Limitations of EPT No information on health status/ integrity Unreliable for immature teeth Not suitable with full coverage restorations Chances of ventricular fibrillation

Test cavity Non localized, acute diffuse radiating

pain Definitive diagnosis: impossible Cavity prepared in the tooth: concealed

position without anesthesia Patient apprised of what to expect &

how to respond

Test cavity Response: cavity preparation stopped &

restored again No response: endodontic access cavity

continued Low speed handpiece & small bur

recommended Full crown restorations & margins

contacting gingival tissue

Test cavity Young teeth: immature roots- invasive

nature questioned Unreliable; response even in necrotic

pulp Response unreliable: anxiety Invasive & irreversible No further information than thermal &

EPT Not justified in modern practice

Laser Doppler Flowmetry

Jafarzadeh .IEJ, 42, 476-490,2009

Optical measuring method- number & velocity of particles conveyed by a fluid flow to be measured

Laser light is transmitted to the pulp by means of a fiber optic probe

Laser doppler flowmetry Scattered light from the moving RBCs in

the circulation will be frequency-shifted, while those from the static tissues remain unshifted.

Reflected light composed of Doppler shifted and unshifted light is returned to photodetectors

Detected & processed -signal measure of the blood flow in the dental pulp

Jafarzadeh .IEJ, 42, 476-490,2009

Laser doppler flowmetry Not useful in teeth with crowns and large restorations Detect only the coronal blood flow of the

pulp, which may not relate to the actual blood flow on the linear scale.

Advantages: Painless diagnosis as compared to thermal

& electric pulp tests Diagnosis of immature or traumatized

teeth

Pulse Oximetry Effective, objective oxygen saturation

monitoring technique - intravenous anesthesia

Consistently determined the level of blood oxygen saturation of the pulp- pulp vitality testing

Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009

Pulse Oximetry Correlation between pulp and systemic

oxygen saturation readings (Schnettler and Wallace1991)- definitive pulp vitality tester

Biox 3740 Oximeter (Kahan et al 1996) Custom‑made Pulse Oximeter sensor holder (Gopikrishna et al 2006)

Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2

Pulse Oximetry Probe containing two LEDs: red light- 660 nm & infrared light (900–940 nm) Measures absorption of oxygenated and

deoxygenated Hb Received by a photodetector diode connected to

a microprocessor. Relationship between the pulsatile change in the

absorption of red light & infrared light : assessed by the oximeter + known absorption curves for oxygenated and deoxygenated hemoglobin,


Pulse OximetryIndications: Recent trauma Primary &

immature permanent teeth

Patient monitoring: sedation

Limitations: Intrinsic interference:

venous blood & tissue constituents, acidity,CO2

Extrinsic interference Well adapting sensor Hb bound to other

gases Extensive

restorationsJafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009

Pulse Oximetry 70%- 100% accuracy

Inverse correlation between saturation values & EPT readings (Radhakrishnan et al 2002)

More sensitive & specific compared to cold tests & EPT (Gopikrishna et al 2007)


Dual Wavelength Spectrophotometry Method independent of a pulsatile

circulation Measures oxygenation changes in the

capillary bed rather than in the supply vessels

Detects the presence or absence of oxygenated blood at 760 nm and 850nm.

Advantage: Uses visible light that is filtered and guided to the tooth by fibreoptics

Divya et al.Contemporary Diagnostic AIDS in Endodontics”. Journal of Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue 06, February 10

Ultraviolet light/Fiberoptic Fluorescent Spectrometry Fluorescence Vital teeth fluoresce normally; necrotic &

RCT teeth do not –Foreman Lighting in the operatory fully suppressed Patient & staff wear suitable protective

goggles Fluorescence from the pulp -substantially

lower than the healthy and decayed dentin fluorescence.

Healthy and decayed dentin patterns differentiatedTyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2

• Issue 2

Photoplethysmography

Optical measurement technique : blood volume changes in the microvascular bed of tissue.

Light source to illuminate the tissue & a photodetector to measure the small variations in light intensity associated with changes in perfusion


Anesthetic test L/A: painful area Block/ infiltration/ intraosseous Vague location of pain Non odontogenic pain:Myocardial

infarction Differentiating between arches PDL- identify source of pulpal pain.

Dentin sterilizing : Silver nitrate, phenol, eugenol & desensitizing substances

Cleansers: Alcohol, chloroform, H2O2, various acids

Restorative materials & liners

Besner, Ferrigno. Practical Endodontics- A Clinical Guide

Tooth surface temperature Fanibunda: pulp circulation maintains

tooth temperature Cholesteric crystals- 10% solution in

chlorinated hydrocarbon solvent(Howell et al)- non vital: lower temperature

Thermistor: vital & RCT teeth- with and without gold crowns (Banes & Hammond)

Consistent (Stoops & Scott)Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2

• Issue 2

Tooth surface temperature Electronic thermography: Infrared

sensor, control unit, thermal image computer, software, color monitor, printer

Differences in deep & superficial areas- not sensitive

Hughes Probeye 4300 thermal video system: sensitive to measure 0.1oc

Adjunct to other diagnostic tests

Patient temperature Baseline temperature: follwed up Patient is improving/ worsening >1000oF : systemic response to

infection

Ultrasound Compliment conventional radiography High resolution, 3D images- inner

macrostructure of the tooth A transducer (a crystal containing probe),

a coupling agent & software Detect cracks in a simulated human tooth Detect vertical root fractures – vital &

nonvital teeth


Ultrasonic Doppler Imaging

Blood circulation detected Distinguish vital teeth from root- filled

teeth: blood flow parameters, waveform, sound

Promising tool- traumatically injured teeth

Power Doppler associated with color Doppler – improved sensitivity to low flow

rates

Yoon et al. JOE- Volume 36, No.3, March 2010

Vital tooth

Non vital tooth

Optical Reflection Vitalometry Preliminary report-1997 (Oikarinen et al) Noninvasive method The pulse of the pulp/oral mucosa. Yet to be clinically accepted &

commercially available.


Evaluation of Sensibility Tests Thermal test: Endo Ice & EPT- evaluated Endo Ice- 0.904 accuracy & EPT- 0.75 Age group 21-50 & vital teeth: more

accurate response to cold test

Jespersen et al. JOE- Volume 40, No.3, March 2014

RADIOGRAPHY-Little value : assess pulp status

Presence & extent of carious lesions

Vital pulp therapy Calcifications Resorptions Periradicular

radiolucencies Tracing fistulous

tracts

Thickness of PDL Periodontal

disease Root & pulp space

anatomy Previous RCT

Bitewing: pulp chamber

Eccentric ray alignment

Beer, Bauman, Kim. Color Atlas of Endodontology

Digital radiography

Variables in diagnostic quality of conventional radiography- controlled

Image- enhanced, colorized and useful patient education tool

Cone Beam Volumetric Tomography First used in

dentistry- Mozzo P et al 1998

Proximity to anatomic structures

Root canal anatomy

Diagnosis: never based solely on radiographic finding

Thank you!!!!

References Endodontic therapy – Weine Endodntics6- Ingle et al Cohen’s sPathways of the Pulp- 10th ed Color Atlas of Endodontics- William T.

Johnson Endodontics- Problem solving in Clinical

practice- Pitt Ford Practical Endodontics- A clinical guide.

Bessner & Ferrigno

Pocket Atlas of Endodontics- Beer H. Jafarzadeh & P. V. Abbott. Review of

pulp sensibility tests. Part I: general information and thermal tests. IEJ, 43, 738-762, 2010

Yoon et al. JOE- Volume 36, No.3, March 2010

Jespersen et al. JOE- Volume 40, No.3, March 2014

endodontic diagnosis

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