Diagnostic criteria and aids in Endodontics

1. ENDODONTIC
DIAGNOSIS
Deepthi P.R.
1st year MDS
Dept of Conservative
Dentistry & Endodontics

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

3. 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

4. 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

5. 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

6. Diagnostic method
METHODS
Pulp testing
Palpation
Percussion
DIAGNOSTIC APPROACHES
Bite test
Test cavity
Staining/ Transillumination
Selective anesthesia
Radiography
Dental history/
Medical history
Evaluation of pain
signs/ symptoms
Newton et al. JOE- Volume 35, Number 12, December 2009

7. 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

8. 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.)

9. 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

10. Rheumatic fever
Potential for SBE after bacteremia
Antibiotic premedication:
 Artificial heart valves: Same antibiotic
coverage: rheumatic fever
Pulp
extirpation
Filing beyond
the apex
Rubber dam
placement
Initial
appointment/
Surgical
appointment
Possibilty of
going past
the apex
Periapical
lesion

11. 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

12. 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

13. 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

14. Diabetes
 Retarded healing: postop radiographs
 Antibiotics: Infection/ surgery
1yearPre op 6 months 2 years1.5 years 3 years

15. Diabetes
 Alteration in blood glucose levels:
physician consultation
 Epinephrine avoided: Increase in blood
glucose levels & tissue sloughs post
surgery
 Levonordefrin
 Barbiturates & sedatives cautiously used

16. Diabetes
 Longer & deeper
anesthesia
 L/A preferred
 Appointments: soon after meals
 Differentiate & manage hypoglycemia/
hypoinsulinism
• Mepivacaine
+Levonordefrin
• Propoxyphene+ Procaine
+Levarterenol bitartarate

17. Hepatitis
 Resistant to normal sterilization
 Intracanal instruments: discarded after
use
 Avoid drugs detoxified in the liver:
Halothane,Erythromycin
 Cautious- Paracetamol

18. 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 removed
Canals enlarged
& filled

19. 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

20. 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

21. Recent change in weight
Weight loss
 Dieting
 Loss of appetite
 Systemic diseases
Weight gain
 Psychogenic reasons
 Hormonal
disturbances
 Pregnancy
 Protect exposed
tooth surfaces after
endodontic therapy
 Salt & water
retention

22. Psychologic problems
 Physical problems: tendency towards
anxiety
 Patients on Tranquilizers/ antidepressants
Converted 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

23. Others
Hyperthyrodism
 No epinephrine
 Increase sedative if needed
Ulcers
 Avoid aspirin & if on antacids- avoid
tetracycline
 Use Penicillin V if needed
Alcoholic
 Cautious with sedatives
 Aspirin avoided

24. 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

25. 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

26. 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

27. Drugs & Medication therapy
• CNS stimulant:
increase
sedative dose
• Sulfonamides:
avoid
procaine
Antidepressants:
Cautious
• GA
• Narcotics
• Antisialagogue
Tetracycline:
• Antacids
• Penicillin
Barbiturates :
cautious
• Dilantin
• Griseofulvin
• Steroids

28. Dental history
 Patient’s objective for treatment- clear
 Appreciation for dental treatment
 Experiences with previous dentist
Pain
relief
Check
up
Oral
systemic
relation
CosmeticsMasticatory
inefficiency

29. 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

30. 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?

31. 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

32. Clinical Tests
Diagnostic tests:
1. EPT
2. Thermal tests
3. Percussion
4. Palpation
5. Mobility
6. Periodontal
evaluation
7. Occlusal evaluation
8. Radiograph
Selective tests for
Difficult Diagnostic
Situations:
9. Test cavity
preparation
10. Anesthetic test
11. Transillumination
12. Biting
13.Staining
14. Gutta percha point
tracing with radiograph

33. Extraoral
examination
 External facial form & features
 Fistulae, erythema, pallor
 Neurologic examination: motor function,
sensitivity, movement
 Lymph nodes: inflammatory,
infectious, tumor like disorders

34. Intraoral examination
Soft tissue examination:
 Swelling/ fistula

35. Intraoral examination
 Crown discoloration: non vital pulp,
removal of discolored dentin, use of
chlorinated soda
 Deep carious lesions/ fractures: visual
examination & probing

36. Percussion test
 Simple, but useful
 Inflammatory condition of the apical
periodontium
 First clinical indications of apical
periodontitis

37. 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

38. 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

39. Palpation
 Vestibular region: apical region of the root
tips
 Tenderness, swelling, fluctuation,
hardness, crepitation
 Tip of index finger
 Usefulness increase
with skill &
clinical experience

40. 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

41. 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

42. Periodontal probing
 Endodontic & periodontic lesions mimic
each other concurrently
 Record probing depths: periodontal
health & prognosis
 Entire circumference probed

43. Periodontal probing
Narrow isolated probing defects:
 Periodontal disease
 Sinus- like trap following periapical
pathosis
 Vertical groove defect
 Cracked teeth
 Vertical root fractures
 External root resorption

44. Tests for Cracked Tooth
Syndrome
Transillumination
 Fiberoptic light
 Coronal cracks/ vertical root fractures
 Minimal background lighting
 Light placed on varied surfaces of
coronal tooth structure/
root after flap refection

45. Transillumination
 Light traverses fracture lines-
visually detected
 Fractured Segment near the
light appears brighter

46. 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

47. Dye staining
3 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

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

49. 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

50. 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

51. 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

52. 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

53. Pulp sensibility tests
Preferred 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
contralateral
teeth
Opposing
teeth
Presumably
healthy teeth-
same
quadrant
Most
suspicious
tooth

54. 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

55. 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

56. 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

57. EPT- Rationale
 A fibers: brief sharp sensation/ tingling
 *No blood flow- pulp becomes anoxic &
A fibers cease to function
*Pitt Ford & Patel 2004

58. Indications
1.Pain in the trigeminal area; referred pain
2. Periodical monitoring of teeth after
trauma
 1-8 weeks lapse before normal response
 EPT: reliable after trauma**
*No response Response : Recovery
Repetitious response :Healthy pulp
Response No response: Degeneration
No response persistent: Necrotic pulp
**Ingle et al 2002,*Bhaskar & Rappaport 1973

59. Indications
3. Assessment of pulpal health before
restorative procedures
 potential prosthetic abutment
4. Pulp preservation procedures & extensive
restorations
5. Differentiate periapical radiolucencies
from normal anatomical structures & non
odontogenic lesions
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010

60. 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

61. 7. Pulp status of transplanted teeth

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

63. Limitations
1. Subjective; measure only nerve supply
2. Thermal tests: not effective in substantial
secondary dentine formation
3. Unreliability of tests: Immature apices,
traumatic injuries, more subjectivity in the
young
4. No correlation with the histologic status
(Contrasting results: Hill, 1986)
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010

64. Limitations
5. Difficult to administer & inconclusive in
children
6. Weaker response- aged pulp
7. Extensive restorations, pulp recession,
pulp calcification
8. Lack of reproducibility
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010

65. 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

66. 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

67. Reversible pulpitis
 Thermal stimuli (cold)- sharp pain
 Subsides as soon as the stimulus is
removed/ in few seconds

68. 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

69. 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

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

71. Periapical conditions
Acute apical periodontitis
 Maybe associated with pulpitis
 Pulp status assessed before treatment
Acute apical abscess
 Negative
Lateral periodontal abscess
 Positive
Chronic apical periodontitis
 Sequel of infected canal system

72. False responses
False 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

73. 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

74. False responses
False 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

75. 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

76. 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

77. 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

78. 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

79. Value of diagnostic tests
 Heat: relatively high sensibility; but least
accurate being the least specific
 Cold test: more accurate than EPT

80. Thermal tests
 Often inappropriately referred to as
‘Vitality tests’
 More reliable than EPT
 Inexpensive & easy-to- use equipment
 Patient’s pain reproduced

81. Thermal tests
• Initial cold sensitivity
• Heat sensitivity- continued pulp deterioration
• Disappearance of cold sensitivity
• Cold stimuli might relieve heat induced pain

82. 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)

83. 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

84. Cold tests
Ice 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

85. 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

86. Cold tests
 Begin with most posterior tooth
 Cotton pellet placed just distal to the
tooth
 Contact with adjacent gingiva or nearby
teeth: false responses

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

88. 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

89. 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

90. 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

91. Cold tests
Carbon 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

92. Cold tests
Mechanism:
 PDJ temperature reduced to <2oC
 Hydrodynamic theory
 Enamel expansion / contraction & acts as
temperature transfer medium
(Linsuwanont et al 2007)

93. Cold tests
Technique
 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

94. Cold tests
Advantages
 Accurate, reliable, consistent, fast &
uncomplicated
 1-2 minutes- without isolation
 Does not affect adjacent teeth
 Intense reproducible response
 Greater accuracy than EPT

95. 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

96. Cold tests
Disadvantages
 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)

97. Cold tests
Ethyl 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

98. 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

99. 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

100. Heat tests
Heated 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

101. 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

102. Heat tests
Warmed 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

103. Heat tests
Electrical 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, 2010
Castelucci. Endodontics Vol.1

104. Heat tests
Frictional heat
 Rubber cup- prophylaxis
 Buccal surface
 Best, easiest & safest
 Gold crown
 Seldom used today

105. Heat tests
Hot 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

106. 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)

107.  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

108. 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

109. Electrical pulp tests
 Benchtop style digital EPT
 Handheld style digital style EPT
 Handheld style analog EPT

110. 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

111. 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

112. 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

113.  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

114.  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

115.  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

116. 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

117.  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

118. Variations in reading/ False
response
Failure 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

119. 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

120. 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

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

122. 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

123. 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

124. 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

125. 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

126. 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

127. 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

128. 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

129. 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

130. 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

131. Pulse Oximetry
Indications:
 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 restorations
Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009

132. 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

133. 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

135. 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
differentiated
Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2

136. 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

137. 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.

138.  Dentin sterilizing : Silver nitrate, phenol,
eugenol & desensitizing substances
 Cleansers: Alcohol, chloroform, H2O2,
various acids
 Restorative materials & liners
Besner, Ferrigno. Practical Endodontics- A Clinical Guide

140. 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

141. 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

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

143. 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

144. 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

145. 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

146. 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

147. 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

148.  Bitewing: pulp
chamber
 Eccentric ray
alignment
Beer, Bauman, Kim. Color Atlas of
Endodontology

149. Digital radiography
 Variables in diagnostic quality of
conventional radiography- controlled
 Image- enhanced,
colorized and useful
patient education tool

150. Cone Beam Volumetric
Tomography
 First used in
dentistry- Mozzo P
et al 1998
 Proximity to
anatomic
structures
 Root canal
anatomy

151. Diagnosis: never based solely on radiographic
finding

152. Thank you!!!!

153. 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

154.  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