ENDODONTICS DIAGNOSIS

Presented by: Guided by:

Rupa Kumari Sah Dr. Vanita Gautam
4th year (2nd phase) Dr. Snigdha Shubham
Roll no.: 24 Dr. Kriti Shrestha
Dr .Sageer Ahmed
Introduction
 Diagnosis
Diagnosis is the correct determination, discriminative
estimation, and logical appraisal of condition found during examination
as evidenced by distinctive signs, marks, and symptoms.
 Provisional diagnosis / Tentative diagnosis:
Identification of disease based on chief complain, history and examination.

 Differential diagnosis:
It is a process of identifying a disease or condition by differentiating it from
all pathological process that have similar sign and symptoms.

 Final diagnosis:
It is the diagnosis arrived at after all the data established from history,
physical examination & case studies, which are collected, analysed &
subjected to logical thicking.
 CASE HISTORY
• Case history is a planned professional
conversation between patient and dentist,
which enables the patient to express his
symptoms, fear and feelings to the
clinicians so that the nature of patient’s
real or suspected illness and mental
attitude may be determined
 CHIEF
COMPLAIN
• The chief complain is a symptoms or symptoms
described by the patient in the own word
relating to the presence of an abnormal
condition .
• It should be limited to single phrase or single
sentence.
• Common chief complains are:
Pain
Swelling
Broken tooth
Loose tooth
Tooth discoloration
HISTORY OF PRESENT ILLNESS
• It is the complete detail of the chief complains.
• The aim of this part of the history is to have a provisional diagnosis
and differential diagnosis before the examining the patient.
SUBJECTIVE INFORMATION OBJECTIVE INFORMATION
History of pain Visual examination
Stimulus of pain Percussion and palpation
Frequency of pain Caries and fractured restoration
Severity of pain Sinus tracts
Duration of pain Tooth fracture
Spontaneity of pain Extensive restoration
Location of pain Periodontal disease, Mobility
Character of pain
RADIOGRAPHIC ASSESSMENT COMPARATIVE TESTING
Tooth length, No. of roots Thermal test
Calcifications, Orifice location Electric pulp test
Number of canals, Radiolucencies Anesthetics test, test cavity
Resorption, Fractures Transillumination

ASSESSMENT OF PULP AND PERIRADICULAR TISSUES

PLAN OF TREATMENT
PAIN
Definition :
• An unpleasant sensory and emotional experience that is associated
with actual or potential tissue damage.
• Most common complaint that leads to dental treatment is pain.
1. According to intensity

MILD MODERATE SEVERE

2. KIND OF PAIN

Sharp, Piercing and Lancinating Dull, Boring, Gnawing and

pain: Excruciating pain:
• This type of pain response is • This type of pain response is
consistent with those usually consistent with those resulting from
associated with excitation of the “A excitation and slower rate of
delta” nerve fiber the pulp. transmission of the “C” nerve fiber in
the pulp.
3. LOCATIZATION OF PAIN

Localized pain: Diffuse Pain:

• Localized when patient can point to a • When the pain is diffuse, however, the
specific tooth or size and site. patient describes an area of
• Sharp, Piercing and lancinating pain in discomfort rather than a specific site.
a tooth responds to cold and easy to • Dull, Boring pain is diffuse and
localize. responds abnormally to heat than to
cold is difficult to localize.
 DURATION OF PAIN

1. Short and specific to stimuli: At times, pulpal pain last only as

long as an irritant is present. E.g. Acute reversible pulpitis is
characterized by pain of short duration, caused by a specific irritant,
which disappear as soon as the irritant is removed.
2. Persistent and Lingering: If the pain persists and if it last for
minutes to hours after the removal of the stimuli, the pulpitis will
usually be irreversible and the patient will require endodontic therapy.
3. Spontaneous pain: it is one that occurs with out any apparent cause
and is usually a pain of long duration which is a symptom of irreversible
pulpitis.
4. Nocturnal pain:
• Pain that occurs on changing the position of head awakens the
patients from sleep and usually is symptoms of irreversible pulpitis.
 Radiation of pain
• Radiation of pain refers to its extension to another site while the initial pain persists.
• Pain may appear in one site and then reappear in another.
• Pain in orofacial region can radiate to head, temporal region and neck mostly of the
same side.
The conditions where radiating pain is The conditions where localized pain is
present present
• Late stages of acute irreversible pulpitis • Reversible pulpitis
• Periapical diseases like acute apical • Initial stages of acute irreversible
periodontitis, acute periapical abscess pulpitis
• MPDS (Myofascial pain dysfunction • Trigeminal neuralgia limited to the area
syndrome) of trigeminal nerve supply
• TMJ pain • Glossopharyngeal neuralgia limited to
• Atypical facial pain the area of glossopharyngeal nerve
supply
 Factors that exacerbate or aggravate or
provocate pain:
• Patient usually knows anything that makes the pain worse.
Diseases Pain aggravating factor
Pulpal pain Hot/cold items, sweet, air breeze, lying down,
nighttime
Trigeminal neuralgia Talking, brushing, shaving, washing the face, air
breeze
Glossopharyngeal neuralgia Swallowing, movement of tongue
Synovitis Clenching of teeth

Myofascial pain dysfunction Chewing, movement of TMJ

syndrome (MPDS) ust after release of biting pressure
Cracked tooth just after release of biting pressure
 Factor that relieve the pain
• Patients are usually aware of factors that relieve pain, e.g., medications
analgesics - somatic pain.
• Examples of disease with pain relieving factors

Diseases Pain relieving factor

Irreversible pulpitis Pain relieved by cold

Periapical abscess Pain relieved on biting

Trigeminal neuralgia No nighttime pain

SWELLING
• Anatomical location (site)
• Duration
• Mode of onset
• Symptoms
• Progress of swelling
• Associated features
• Secondary changes
• Impairment of function
• Recurrence of swelling
Past medical history
• Anemia
• Bleeding disordes
• Cardiorespiratory disorder
• Drug treatment and allergies
• Endocrine disorders
• Gastrointestinal disorder
• Hospital admission and surgeries
• Infections
• Jaundice and liver disease
• Kidney disease
Past dental history
Significance
• From past dental history we can assess the attitude of patient towards
dentistry.
• Knowledge of patient's past experience during and following the
administration of a local anaesthetic may alert the dentist to
investigate about possible allergy to the anaesthetic agent and may
anticipate possible syn- cope during administration of local
anaesthetics in future.
• The frequency of dental prophylaxis may be an available guide in
evaluating periodontal condition and provide the dentist with
prognostic information.
Personal history
• Diet
• Adverse habit
• Oral hygiene
• Parafuntional habit
Diagnostic methods in
endodontics
1. Visual and tactile inspection:
a) Hard tissues
b) Soft tissues
- Gingiva
- Periodontium
2. Percussion
3. Palpation
4. Mobility and depressibility
5. Bite test
6. Radiography
• Intraoral periapical radiographs
• Bitewing radiographs
• Digital radiographs
• Cone beam computed tomography

7. Assessment of pulp vitality

a) Neural sensibility tests
-Thermal tests
-Heat testing
-Cold testing
-Electric pulp test
-Anaesthetic test
-Test cavity
b) Pulp vascularity tests
i. Pulse oximetry
ii. Laser Doppler flowmetry
iii. Recent technologies
- Dual-wavelength spectrophotometry
- Thermography
- Crown surface temperature
- Transmitted light photoplethysmography
EXTRAORAL EXAMINATION
• Facial symmetry
• Lymph node examination
INTRAORAL EXAMINATION
• Soft tissue examination: Swelling / fistula
• Crown discoloration:
- Non vital pulp
- Deep carious lesion
- Fractures: visual, examination & probing
 PERCUSSION

• It is an act of striking a portion of body with fingers or an instrument to

evaluate the condition of underlying structures by careful attention to
sound or echo produced.
• But in case of dental percussion we evaluate the condition of
periodontal ligament (pdl) by giving additional external pressure by
means of striking from a metal object.
• If periodontal ligament is inflamed, one will not be able to withstand
this force and will have pain.
• The back surface of mouth mirror or probe can be used to strike on to
the tooth.
Types of percussion (in case of oral examination):
1) To evaluate pain response.
• Vertical percussion - Evaluating apical periodontal ligament
inflammation/periapical inflammation.
• Horizontal percussion - Evaluating lateral periodontal ligament
inflammation.
2) To evaluate sound response:
• Woody/dull sound in tooth ankylosis/fracture
 PALPATION
1. This simple test is done with the
fingertips, using light pressure to
examine tissue consistency and pain
response.
2. Its value lies in locating the swelling over
an involved tooth and determining the
following:
• Whether the tissue is fluctuant and enlarged
sufficiently for incision and drainage
• Presence, intensity, and location of pain
• Presence and location of adenopathy
• Presence of bone crepitus
 MOBILITY -
DEPRESSIBILITY
Miller's Tooth Mobility Index
• First-degree mobility: First distinguishable sign of
movement greater than normal
• Second-degree mobility: Horizontal tooth movement
within a range of 1 mm
• Third-degree mobility: Horizontal tooth movement
greater than 1 mm or when the tooth can be depressed.
Endodontic treatment should not be carried out on teeth
with third-degree mobility unless mobility is reduced
when pressure in the periodontium has been relieved
 BITE TEST
• The bite test is useful in identifying a cracked tooth or fractured cusp
when pressure is applied in a certain direction to one cusp or section of
the tooth
• The Tooth Slooth and the Frac Finder are the popular commercially
available devices for the bite test.
 RADIOGRAPHY
According to Walton and Gomez, radiographs have the following applications:
• Help in the diagnosis of hard tissue alterations in the teeth and periapical structures
• Determine the number, location, shape, size, and direction of roots and root canals
• Assess anatomy, size, and alterations in the pulp chamber
• Detect procedural errors such as perforations, ledges, transportation, and instrument
separation
• Locate root tips prior to surgery
• Estimate and confirm the length of canals
• Aid in the evaluation of obturation
• Facilitate the examination of soft tissues for tooth fragments and other foreign bodies
following traumatic injuries
• Aid in localizing a hard-to-find apex during root-end surgery
ASSESSMENT OF PULP VITALITY
 1. THERMAL TEST
A.HEAT TEST
Materials used are as follows:
• Electrical heat carrier (Fig. 6.36a)
• Hot gutta-percha stick (>65.5°C)
• Others:
- Hot water under rubber dam isolation
- Hot burnisher
- Hot compound
- Dry rubber polishing wheel
 METHODS
• The heat test can be performed using different techniques.
• If higher temperature is needed to elicit a response then heated gutta percha , hot
burnisher ,hot water, etc. can be used.
Heated gutta percha stick- most common method for heat testing.

In this method ,tooth is coated with a lubricants such as petroleum jelly to prevent
the gutta percha adhering to the tooth surface

Then, heated gutta percha is applied at the junction of cervical and middle third of
the facial surface of tooth

patient response is noted and should be immediately removed

• No response non vital pulp
• Mild to moderate degree of pain that
subsides within 1 to 2 seconds after
stimulus is removed vital pulp
• Strong painful response that subsides
within 1 to 2 seconds after stimulus is
removed Reversible pulpitis
• Moderate to strong painful response
for several seconds or longer, after
removal of stimulus
Irreversible pulpitis
MECHANISM
OF HEAT
TEST(VAN
HASSEL’S
TEST)
 B. COLD TEST
Materials used are as follows:
• Endo- ice (1,1,1,2 – tetrafluoroethane)
(most common) (-15 to -26°C)
• CO2 snow (dry ice) : -78 °C
• Ice cold water under rubber dam isolation
• Ethyl chloride (boiling point -41°C)
• Freon (-21°C)
 MECHANISM
OF COLD
TEST
(BRANNSTRO
M’S THEORY)
Thermal Test Rational
• First reported by jack in 1899
• Inexpensive & east to use equipment
• More reliable than EPT
• Patients pain reproduced

Heat • C fibers (Slower)

• Dull long lasting pain
test
• A fibers faster
• Hydrodynamic movement of fluid in dentinal
Cold test tubules
• Sharp localized pain
ELECTRIC PULP TEST
• The electric pulp tester when testing for pulp vitality, uses nerve
stimulation.
• The objective is to stimulate a pulpal response by subjecting the tooth
to an increasing degree of electric current.
• A positive response is an indication of vitality and helps in
determining the normality or abnormality of that pulp.
• No response to the electrical stimulus can be an indication of pulp
necrosis.
PROCEDURE
• Describe the test to the patient in way to reduce anxiety of patient
and will eliminate a biased response.
• Isolate the area of control tooth and tooth to be tested with cotton
rolls and saliva ejector and dry all the tooth .
• Check the electric pulp tester for function and determine the
current is passing through the electrode.
• The test is always performed on the control tooth prior to testing
tooth in question.
• Apply an electrolyte (waterbased gel or toothpaste)on tooth.
• Place it against the dried enamel of crown’s occlusobuccal or
incisiolabial surface. Avoid contacting adjacent gingival tissue
with electrode and electrolyte ;this would create false report.
• Location of probe tip:
• For anterior tooth: incisal 3rd
• For premolars : on buccal cusp
• For molars: middle third of the mesiobuccal cusp
Complete the circuit :Retract the patient cheeks away from the tooth
electrode and the electric circuit is completed by either:-

-a ground wire (lip clip) is placed over the patient’s lip in contact with oral
mucosa.
-or clinician instructs the patient to rest the finger on the metal sheath of the
tester.

Turn the rheostat slowly to introduce minimal current into the tooth and
increase the current slowly. Ask the patient to indicate when the sensation
occurs by using such words as tingling and warmth. Record the result
according to numeric scale on the pulp tester.
• Repeat the foregoing for each tooth to be tested. The clinical
interpretation of the pulpal response.
• To prevent the errors repeat the test 2 to 3 times for accuracy.
• EPT is unreliable in testing immature permanent teeth and is not
recommended for assessment of concussed teeth.

• It is not done on teeth with full coverage restorations because an

electrical stimulus cannot pass undistorted through acrylic,
ceramic, or metallic portions of crown so application of dry ice is
test of choice in this situation.
• Normal response:
A positive response occurs at same neural excitation threshold to contralateral
tooth . eg. tooth to be tested is 11 then control will be 21 and both will show
response at same numerical value in the EPT.

• Negative test :
Denotes a non vital tooth which fails to respond even when the tester is at the
highest electric excitation value.

• Early response:
This denotes a diseased state of the pulp as the tooth respond to the lower
threshold than the control tooth
• Delayed response: Denotes diseased pulp where the tooth
responds to higher value than the control tooth.

• False positive response:

-Teeth with acute alveolar abscess because gaseous or liquefactive
necrotic product with in pulp canal can transmit the electric current .
-Electrode in contact with gingiva.
In multiple rooted tooth pulp may be vital in one or more root canals and
necrosed in other , elicits the false positive response.
• False negative response :
- Recently traumatized tooth
- Recently erupted tooth with immature apex
- Patient with high pain threshold
- Calcified channels and fibrotic pulp
- Electrical deficiency in the pulp tester
- Patient pre-medicated with analgesic and tranquilizer
- Partial necrosis of pulp sometimes is indicated as total necrosis by EPT.
- Teeth with extensive restoration or pulp protecting base.
- If not properly isolated
INDICATIONS:
• Reversible pulpitis : shows early response.
• Irreversible pulpitis: shows delayed response.
• Pulp poly or chronic hyperplastic pulp :requires more current to show response.
• Necrotized pulp : no response
• Immature tooth : false negative
• Concussed tooth :negative
• Traumatized tooth :negative

CONTRAINDICATIONS:
• Cardiac pacemaker patients
WHICH TEST IS ACCURATE ?
• The diagnostic accuracy of cold test is 86% , EPT is 81%, and heat test
is 71%. Hence, clinically a combination of cold test followed by EPT is
recommended.
• Following traumatic dental injuries, the reaction to the tests of pulp
vitality may be negative for as long as 3 months in case of root
fractures or trauma to supporting structures. Hence, sensitivity tests
may be negative initially and have to be monitored over a period of
time.
 ANESTHETIC TEST
• This test is restricted to patients who are in pain at the
time of the test when the usual tests have failed to
identify the tooth.
• Objective is to anesthetize one tooth at a time until the
pain disappears and is localized to a specific tooth.
• Here, first the posterior tooth in the area suspected of
being the cause of pain is injected with anesthesia.
• If the pain persists when the tooth has been fully
anesthesized, anesthesize the next tooth mesial to it and
continue to do so until the pain disappears.
TEST CAVITY
• This test is performed when other methods of diagnosis have failed.
• The test cavity is made by drilling through the enamel- dentin junction
of an unanesthesized tooth.
• Sensitivity or pain felt by the patient is an indication of pulp vitality.
• This test can cause iatrogenic damage.
 PULP VASCULARITY TESTS
PULSE OXIMETRY
• It is noninvasive method to measure the oxygen saturation levels during the
administration of anesthesia or other medications with the help of a finger, ear,
or foot probes.
PRINCIPLE:
• The pulse oximeter sensor consists of two light emitting diodes, one to transmit red
light( 660nm), other to transmit infrared light (850nm) and a photodetector on opposite
side of vascular bed.
• When LED transmits blight through vascular bed, different amount of light is absorbed
by oxygenated and deoxygenated hemoglobin.
• Pulsatile change in blood volume causes change in the amount of light aborbed by
vascular bed and this change is analyzed in pulse oximeter to evaluate saturation of
arterial blood.
 LASER DOPPLER FLOWMETRY
It measures the rate of blood flow in a tissue.
Principle:
• The laser light is transmitted through a fiberoptic source and placed onto the tooth
surface.
• The light enters a tooth and gets absorbed by the red blood cells which leads to a shift in
the frequency of the scattered light.
• This shift in frequency does not occur in light that is absorbed by stationary objects.
• The proportion of Doppler shifted light is detected with the help of photodetector.
• This principle is used to ascertain the presence of blood movement within the pulp
space.
• LDF can be used to differentiate a healthy, traumatized tooth with reduced blood supply
from a nonvital tooth.
• Care has to be taken that there are no other motion artifacts during the
procedure and this device is expensive so it is not routinely used in
dental practice.
REFERENCE
• Grossman’s Endodontic Practice (14th edition)
• Textbook of Endodontics Nisha Garg
THANK YOU