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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
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
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
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
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
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
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)
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
Limitations 5. Difficult to administer & inconclusive in children6. Weaker response- aged pulp7. Extensive restorations, pulp recession, pulp calcification8. Lack of reproducibility
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
Interpretation- Diagnosis Immediacy, intensity & duration of
response Outcome: never certain No particular response- unique to
specific pathologic states
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
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
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
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
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
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
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
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
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
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
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
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
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
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,
Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009
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)
Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009
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
Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
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
Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
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.
Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
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