DIAGNOSIS AND TREATMENT PLANNING IN CONSERVATIVE DENTISTRY AND
ENDODONTICS
• Introduction
 Definition : Diagnosis (Accord...
iii. Clinical examination of trauma
iv. Examination of amalgam restorations
v. Examination of cast restorations
vi. Examin...
2. Palpation
3. Percussion
4. Mobility and Depressability tests.
5. Periodontal examination
6. Radiographic examination
7....
* Conclusion
* References
Introduction
Pretreatment considerations consisting of patient assessment, examination and diagn...
diagnostic probability. The most likely diagnosis is referred to as the “Working diagnosis”, the
“presumptive diagnosis” o...
3. Systemic diseases and cardiac abnormalities like rheumatoid heart diseases that
demand less strenuous procedures or pro...
Reveals information about past dental problems and treatment. If a patient has difficulty
tolerating certain types of proc...
Chief complaint
* Risk Assessment
- Patient should me made aware of their risk status.
- This knowledge encourages them to...
 Non-fluoride area
 No fluoride tooth paste
 Fluoridation area
 Fluoride tooth paste used
Plaque control
 Infrequent,...
• Blood Pressure : Normal – 120/80 mm Hg for below 60 years.
140/90 mg Hg above 60 yrs.
It must be stressed that no patien...
- Designated as UL 6
 Federation Dentaire – common in Europe
International (FDI)
- 1 2
4 3
- Designated as 26
 Universal...
- Lesion visible on a wet surface is all the way through the enamel and may be into
dentine.
- Cavitated lesions present a...
- Incipient caries on facial and lingual smooth surfaces appear as white spot which will
partially or totally disappear. F...
- Certain degree of attrition is expected with aging, but in case of a significant abnormal
attrition, the patients functi...
- Upper lateral incisors, upper and lower second premolars and third molars most
commonly affected.
2. Amelogenesis imperf...
• Marginal ridge incompatibility
• Improper proximal contacts
• Recurrent caries.
Examination of cast restorations
- Is ev...
- The static relationship of the teeth in intercuspal position (ICP) should be examined to
determine the horizontal and ve...
Mildest pulp discomfort, experienced when no inflammation is present; is hyper reactive
pulpalgia
Quality of pain: Pulp pa...
2. Periodicity: Symptoms have temporal pattern or sporadic or occlusional, recurrent pain.
3. Frequency: Continuous or Int...
- Heat, cold, sweets, percussion, biting, chewing, palpation.
Diagnosing toothache.
A patient complaining of toothache is ...
1. History Slightly sensitivity or
occasional pain
Constant or intermittent
pain
2. Pain Momentary and immediate,
sharp in...
Acute Periodontal abscess
- Forms at the base of deep periodontal pocket, presentation similar to acute apical
periodontit...
May become infected or may become
And flare up into an cystic, which also
Acute apical abscess can become infected
(Phoeni...
The radiographic image of occlusal fissure is complex and is such that caries would only be
visible when it affects the ba...
• The only way to guard against these limitations is to continually correlated clinical
and radiographic findings.
4. Temp...
Benedict (1928) first noted fluorescence of organic components of teeth and also the difference
in fluorescence between so...
Both instruments measured the electrical conductance between the tip of a probe placed in the
fissure and a connector atta...
Its use allows a specimen to be reimaged after further exposure to a clinically relevant
environment. When a magnetic fiel...
10. Stray – Field Imaging (STRAFI)
- is a magnetic resonance microscope, that shows outer and inner contours of the teeth....
3. Swab test
• Developed by Grainger 1965.
• Swab is incubated in the medium for 48 hrs, change in pH is indicative of deg...
• Soft tissue
Color: Normal color of gingiva is pink, change from this is easily visualized in
inflammatory conditions.
Co...
• Tooth is struck with a quick, moderate blow initially with low intensity by the
finger, then with increasing intensity b...
• Endo treatment should not be carried out on teeth with third degree mobility
unless mobility is reduced by drainage of a...
Radiographic interpretation
- A single root canal should appear tapering from crown to apex, sudden change in
appearance o...
• Uses a rigid aluminium / selenium coated photoreceptor plate. Plate is electrically
charged, placed in a water proof cas...
- Heat test
- Can be performed with hot air, hot water, hot burnisher, hot gutta percha, hot
compound polishing of crown w...
• EPT false readings
1. A false positive response means pulp is necrotic, patient feels sensation in tooth.
Reasons
• Elec...
• This technique uses a helium neon laser light beam that is directed into the tooth.
• Light that contacts a moving objec...
• It widely used in medicine, based on the phenomenon of reflection of ultra sound
waves (echoes) at interfaces between ti...
- Irreversible pulpitis
- Necrotic pulp
- Infection due to endodontic failure
• Diagnostic case focks are obtained and thi...
• Ritchey et al 1957 - reported various cases of incomplete fractures with
subsequent pulpitis
• Cameron 1964 – termed “cr...
Treatment plan sequencing
• Urgent phase
• Control phase
• Re-evaluation phase
• Definitive phase
• Maintenance phase.
Urg...
Rehavioral - help the patients develop skills, knowledge and knowledge to alter
deleterious dietary intake and improve ora...
Proper diagnosis and treatment planning play a critical role in the quality of dental care.
Each patient must be evaluated...
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Diagnosis and treatment planning in conservative dentistry and endodontics

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Diagnosis and treatment planning in conservative dentistry and endodontics

  1. 1. DIAGNOSIS AND TREATMENT PLANNING IN CONSERVATIVE DENTISTRY AND ENDODONTICS • Introduction  Definition : Diagnosis (According to McGhee – Grossman)  Differential diagnosis  Prognosis  Treatment plan (Sturdvent – operative dentistry 4th edition)  Working diagnosis  Definition diagnosis * Pretreatment considerations - Chief complaint - Medical History - Sociologic and Psychologic review. Past - Dental History Present - Risk Assessment. * Examination and Diagnosis - Extra oral examination - Intra oral examination a. Soft tissue Charting and records b. Hard tissue Tooth denotation systems. c. Clinical examination of caries. - Occlusal caries. - Smooth surface caries. - Root caries ii. Clinical examination of additional defects - Tooth wear - Developmental defects
  2. 2. iii. Clinical examination of trauma iv. Examination of amalgam restorations v. Examination of cast restorations vi. Examination of tooth colored restorations vii. Examination of Periodontium viii. Examination of occlusion ix. Examination of Pain - Definition (According – Fields IASA) - Pulp pain – classification (Ingle – 5th edition endodontics) - Diagnosing tooth ache. * Diagnostic aids in caries. Old Trends 1. Visual Detection 2. Tactile sensation with explorers 3. Radiographs 4. Temporary elective separation and impression. 5. Caries detector dyes. Newer Trends 1. Computer based image analysis. 2. Quantitative light induced fluorescence (QLF) 3. Electro conductness measurements (ECOM) 4. Digital fibre optic transillumination (DIFOTI) 5. Endoscopic filtered fluorescence (EFF) 6. Alternating current infedence spectroscopy technique. 7. Megnetic resonance micro imaging (MRM) 8. Ultra sonic Imaging 9. Diagnodent laser diode fluorescence 10.Strey field imaging (SFRAF1) 11.Radio visiography (RVG) 12.Caries activity tests * Diagnostic AIDS in Endodontics 1. Visual and Tactile Inspection
  3. 3. 2. Palpation 3. Percussion 4. Mobility and Depressability tests. 5. Periodontal examination 6. Radiographic examination 7. Xeroradiography. 8. Digital substraction radiography. Vitality tests 1. Thermal tests Heat & Cold 2. Electric Pulp test 3. Test cavity 4. Anaesthetic Test 5. Laser Doppler Flowmetry (LDF) 6. Pulse – Oximetry. 7. Liquid crystal testing. 8. Hughes probeye camera Newer Methods - Ultra Sounds Real time imaging - Computerized Tomography - Magnetic resonance imaging - Computerized export system. - Tuned aperture computed tomography (TACT) - Infrared Thermography. * Diagnosis of cracked tooth syndrome * Treatment Planning. 1. Urgent Phase 2. Control Phase 3. Re-evaluation Phase 4. Definitive Phase 5. Maintenance Phase
  4. 4. * Conclusion * References Introduction Pretreatment considerations consisting of patient assessment, examination and diagnosis and treatment planning are the foundation of sound dental care. These considerations follow a step wise progression as the diagnosis and treatment plan depend on thorough assessment and examination of the patient. Diagnosis “Is defined as correct determination, discriminative estimation and logical appraisal of conditions found during examination as evidenced by distinctive marks, signs that are characteristic of health or disease”. - McGhee. Diagnosis “is the process of identifying a disease by its signs, symptoms and results of various diagnostic procedures” - Grossman. Differential diagnosis Is the list of most likely and possibly diagnosis based on available information”. The final diagnosis is only arrived at, after other diseases on this list have been eliminated through further investigations or consultations. - Webster Dictionary. Prognosis “Predicting the likely outcome of a disease based on condition of patient and action of disease. - Webster Dictionary Treatment plan “Is a carefully sequenced series of services designed to eliminate or control etiological factors, repair existing damage and create a functional, maintainable environment. – Text book of operative Dentistry – Sturdvent. “Working diagnosis”: after eliminating as many diseases (differential diagnosis). From consideration as the information justifies, the remaining possibilities are ranked in the order of
  5. 5. diagnostic probability. The most likely diagnosis is referred to as the “Working diagnosis”, the “presumptive diagnosis” or “Clinical impression” or “Provisional diagnosis” Gary C. Coleman. * Additional tests and preliminary treatment limits the list to a single disease, which is the “Definitive diagnosis”, “Final diagnosis” or just “diagnosis”. The final diagnosis determines the definitive management of the problem – Gary C. Coleman. PRETREATMENT CONSIDERATIONS * Chief Complaint - Before initiating any treatment it is important to determine the patients chief complaint or the problem that initiated own words. - It is recorded in patients own words. - Patient should be encouraged and guided to discuss all aspects of current problem, including onset, duration symptoms and related factors. Symptoms Are the units of information sought in clinical diagnosis. It is defined “as phenomena or signs of a departure from the normal and indicative of illness”. By Gross man. Subjective symptoms Are those symptoms ascertained by the clinician through various tests. It thus follows that the corners or pillars of a correct clinical diagnosis are a. Good case history b. A thorough clinical examination and c. Relevant investigations / diagnostic tests. Medical history - Medical history helps identify conditions that could alter, complicate or contra indicate proposed dental procedures. - For example : 1. Communicable diseases : Viral infections like hepatitis, AIDS that require special precaution procedures or referral. 2. Allergic or medications : Patients allergic to local anesthetics like “Novacaine” may contra indicate use of certain drugs.
  6. 6. 3. Systemic diseases and cardiac abnormalities like rheumatoid heart diseases that demand less strenuous procedures or prophylactic antibiotics coverage. 4. Physiologic changes associated with aging : may alter clinical presentation and influence treatment. - Even though there are virtually no systemic contraindication to endotherapy (except uncontrolled diabetes or recent myocardial infarction), a recent, comprehensive medical history is mandatory. - Patients with systemic conditions like heart valve replacement, a history of rheumatic fever or advanced AIDS require antibiotic prophylaxis. - Patients who are on anticoagulant therapy may need to have the dose reduced or suspended. - During endodontic treatment, clinician must know what drugs the patient is taking so that adverse drug interactions can be avoided. - In case of patients with mental or emotional disorders, medical consultation before diagnostic examination would be best. * Sociologic and Psychologic review. - During initial visits the clinician should ascertain the patients attitudes, priorities, expectations and motivations towards dental care. - Attitudinal information combined with assessment of the patients dental appreciation, educability habits, parental history, occupation and financial situations can indicate the patients commitment to dental care. - Diet - since diet plays a major role in dental caries and is of importance in tooth wear. - Habits - it is relevant to enquire about tooth, cleaning habits and the tooth paste used as well as other habits. Example smoking will increase the likelihood of surface stains on teeth. Grinding habits, an erosive diet or alcohol consumptions are also relevant. Past Dental History Present Past dental history
  7. 7. Reveals information about past dental problems and treatment. If a patient has difficulty tolerating certain types of procedures or has encountered problems with previous dental care, an alteration of the treatment or environment may help avoid future complications. Also important to know the date and type of available radiographs to ascertain the need for additional radiographs and minimize the patients exposure to radiation. Present dental history The most common complaint that leads to dental treatments is pain or swelling. Questions like when did you first notice this (Inception), factors that improve or worsen the condition (Provoking factors). Factors that relieve the pain host or cold (attenuating factors). (Frequency ) of pain (Intensity) of pain is mild, moderate or severe. (localized or referred) location of pain (Duration) of pain, momentary or long lasting (Postural) pain is when you bend or lie down. (Stimulated or spontaneous) pain. - (Quality) of pain is sharp, lancinating, stabbing, dull or throbbing, growing. Treatment Diagnosis Consult Referral Data Evaluation Radiographic Interpretation Diagnostic Physical Tests Inspection Medical Dental Patient History History Interaction
  8. 8. Chief complaint * Risk Assessment - Patient should me made aware of their risk status. - This knowledge encourages them to keep appropriate recall appointments and to become involved in their own preventive care. - A cluster analysis model for caries risk assessment was applied to determine, the natural grouping of individuals among sixty 8-10 year old children and to identify the most significant set of markers for risk assessment. - Risk clusters were obtained with initial clinical and bacteriological measurements including DMF + DMFS, active caries, mutans streptococci and lactobacillus counts in plaque or saliva and synderi test. - This set of markers identified 86% of children at high risk and 94% of children in low risk cluster. Sanchez-Perezl et al (Arch oral Biol.2004, Sept. 49(9) 719-25) CARIES RISK ASSESSMENT High risk Low Risk Social History  Socially deprived  High caries in siblings  Lower knowledge of dental disease  Irregular attendance  Ready availability of snacks  Low dental aspirations  Middle class  Low caries in siblings  Dentally aware  Regular attendance  Work does not allow regular snacks.  High dental aspirations Medical History  Medically compromised  Handicapped  Xerostomia  Long term cariogenic medicine  No medical problem  No physical problem  Normal salivary flow  No long term medication Dietary habits  Frequent sugar intake  Infrequent sugar intake Fluoride use
  9. 9.  Non-fluoride area  No fluoride tooth paste  Fluoridation area  Fluoride tooth paste used Plaque control  Infrequent, ineffective cleaning  Poor manual control  Frequent, effective cleaning  Good manual control Saliva  Low flow rate  Normal flow rate Clinical Evidence  New lesion s  Premature extractions  Anterior caries or restorations  Multiple restorations  History of repeated restorations  Partial dentures  No new lesions  Nil extraction for caries  Sound anterior teeth  No or new restorations  Restorations inserted year age.  No appliances * Examination and diagnosis Extra oral examination • General – Built, gait • Local - Should begin while clinician is taking patients dental history by observing the patients facial features. - Look for facial asymmetry or distension that might indicate swelling of odontogenic origin or systemic ailment. - Patients eye for papillary dilation or constriction that may indicate systemic disease, premedication or fear. Lips -> competent or incompetent. - Patients skin for any lesions (S), if more than one, whether lesions appear at random or follow neural pathway. - Examination of sub mandibular glands sub-mental and cervical nodes. For abnormalities in size, texture, mobility and sensitivity to palpaton (Bimanual palpation). - Masticatory muscles for pain or tenderness, examination of TMJ – deviation, clicking, tenderness. - Vital signs
  10. 10. • Blood Pressure : Normal – 120/80 mm Hg for below 60 years. 140/90 mg Hg above 60 yrs. It must be stressed that no patient with or without a dental emergency, should be treated when his diastolic B.P. is over 100 mm Hg. - Pulse Rate and Respiration : Normal : Pulse : 60-100 /minute. Respiration : 16-18/minute - Temperature : Normal body temperature : 37o C. 98.6 o F. - An elevated body temperature is one indication of total body reaction to inflammatory disease. - A temperature above 98.6 of but less than 100o F indicates localized disease (Summers G.W. 1976). Intra oral examination Soft tissue Visual examination and palpation of buccal muocsa buccal vestibules, hard palate, soft palate, lips, tonsillar areas, tongue and floor of the mouth. - Hard tissue - Charting and Records : Charting system includes identification data, medical history, dental history, clinical examination, diagnosis, treatments planning documentation or informed consent, progress notes and completion notes. - Charting system is necessary for many reasons including : * Proper care * Quality assessment * Legal proceedings * Forensic uses. - Tooth Denotation system  Palmer system - common in U.K. 8 -1 1-8 8 -1 1-8 Designated as 6  Letter code - UR UL LR LL
  11. 11. - Designated as UL 6  Federation Dentaire – common in Europe International (FDI) - 1 2 4 3 - Designated as 26  Universal – Common in U.S.A. - 1 16 32 17 - Designated as 14 * Clinical examination of caries The pre requisites for caries diagnosis are :- • Good lighting • Clean teeth • A three in one syringe so that teeth can be viewed both wet and dry. • Sharp eyes with vision aided by magnification • Reproducible bitewing radiographs Examination of caries on occlusal surfaces - Caries is most prevalent in faulty pits / fissures of occlusal surfaces where developmental lobes of posterior teeth foiled to coalesce partially or completely. - Occlusal surface is diagnosed as diseased if any one of the findings is present. • Chalkiness or softening of the tooth structure forming the fissure / pit. • Brown – grey discoloration radiating peripherally from the fissure / pit. • Radiolucency beneath the occlusal enamel surface - Active uncavitated lesion is white, often with a mark surface. - Corresponding inactive lesion may be brown. - These enamel lesions are not visible on a bitewing radiograph. - Enamel lesion that is only visible on a dry tooth surface is in the outer enamel.
  12. 12. - Lesion visible on a wet surface is all the way through the enamel and may be into dentine. - Cavitated lesions present as micro cavities with or without grayish discoloration of enamel - A lesion missed on visual examination but found on radiograph - “Hidden caries”. Examination of caries on proximal surfaces. - Difficult to see a carious enamel lesion as they form just cervical to contact area and vision obscured by adjacent tooth. - Because if lesion is discovered clinically, it is usually at a relative late stage when it has progressed well into dentine and seen as pinkish grey area shinning up through marginal ridge. - Bitewing radiographs – important in diagnosing approximal caries in both enamel and dentine - And once lesion is visible in enamel on bitewing radiograph it is usually in dentine when examined histologically - Approximal enamel lesion appears as dark triangular area in enamel on a radiograph, apex towards the enamel dentine junction. - Caries on approximal root surface is visible on bitewing radiograph; sometimes it is confused with a cervical radio lucency or “burnout”. This is a perfectly normal appearance at the gap between dense enamel over crown of the tooth and crest of alveolar ridge where x-ray pass tangentially through dentine of root (not through enamel or bone) giving a relatively radio lucent appearance. - Transmitted light used in diagnosis of approximal caries in anterior teeth. - In posterior teeth, a stronger light source is required and fibre optic lights with beam reduced to 0.5 mm diameter have been used. * Examination of root surface caries - Uncavitated, active lesions are close to gingival margin and have mark surface. - Inactive lesions are further from the gingival margin, white or brown in color with a shiny surface. - Active lesions are soft, plaque covered arrested lesions are hard and plaque free.
  13. 13. - Incipient caries on facial and lingual smooth surfaces appear as white spot which will partially or totally disappear. From vision on wetting. Drying again will cause it to reappear. - This disappearing – reappearing phenomenon helps to distinguish between smooth surface incipient caries and non-hereditary enamel hypocalcification (Does not disappear on wetting). Clinical examination of additional defects • Tooth wear • Chemical erosion: is the loss of surface tooth structure by chemical action in the continued presence of demineralizing agent (Acid.) • Resulting defective surface is smooth • Exogenous acidic agents such as gastric fluids cause generalized erosion of lingual, incisal and occlusal surfaces. • Idiopathic erosion - cervical wedge shaped defect (angular), predominant causative factor is heavy force is eccentric occlusion resulting in flexuring of the tooth. • This tensile stress in the effected wedge shaped region on the tooth side away from the tooth bending direction, results in loss of surface tooth structure by Micro fracture termed “abfraction”. • Abrasion: is abnormal tooth surface loss resulting from direct frictional forces between the teeth and external objects, or from frictional forces between contacting teeth in the presence of an abrasive medium. • Seen as a sharp wedge shaped notch in the gingival portion of facial aspect of teeth, surface of defect is smooth. • Usually caused by improper brushing techniques • Present on such defects does not automatically warrant intervention, rather it is important to determine and eliminate the cause. Attrition Is mechanical wear of incisal or occlusal tooth structure as a result of functional or parafunctional movements of the mandible.
  14. 14. - Certain degree of attrition is expected with aging, but in case of a significant abnormal attrition, the patients functional movement must be evaluated and enquiring made about any habits creating this problem such as tooth grinding or bruxism usually due to stress. - Developmental defects - Acquired - Hereditary • Acquired 1. Enamel hypoplasia and Hypomineralization - Hypoplastic enamel results from production of reduced amount of matrix which natures normally, because enamel is pitted or thin but of normal hardness. - Hypomineralized enamel results when normal amount of matrix fails to achieve full mineralization. Affected enamel has normal shape and thickness but has opaque chalky white appearance. - Majority of systemic disturbances last only a few weeks and because the defect takes the form of narrow horizontal band around affected crown and crowns - Hypomineralization affecting occlusal surfaces appear white yellow or yellow brown opacities that chip off easily leading to unprotected dentine, plaque stagnation and rapid caries development. 2. Dental Fluorosis - Occurs when total daily intake of fluoride ion is high while the enamel is undergoing pre eruption formation and maturation. - Appears as chalky – white flecks or confluent blotches and brown discoloration sometimes accompanied by pitting of enamel 3. Tetracycline staining - Occurs when drug is taken by infants and young children or pregnant women where in the developing permanent teeth are affected showing horizontal band of discoloration. Hereditary conditions 1. Hypodontio, microdontia -> teeth abnormal is shape or size.
  15. 15. - Upper lateral incisors, upper and lower second premolars and third molars most commonly affected. 2. Amelogenesis imperfecta: - Two different patters a. Generalized hypoplasia : defect in enamel matrix formation, appear yellow with thin enamel or granular or pitted enamel surfaced which may pick up stain. b. Generalized hypomineralization : incomplete mineralization of normal matrix. Enamel may appear stained and darkened or dull and chalky –white. 3. Dentinogenesis imperfecta : deficient formation of dentin and is characterized by brown opalescent discoloration of teeth which are prone to early fracture and excessive wear. * Examination of trauma - Crowns of the teeth examined for fracture, pulp exposure and color changes. - Displacement or looseness of teeth should be noted. - Check for abnormalities of the occlusion. - Vitality of the injured and adjacent teeth must be tested. - Periapical radiographs taken to look for root fracture. - Where fractures of maxilla or mandible are suspected, further radiographs of facial skeleton required. - At subsequent recall visits the color of the tooth and further vitality tests and periapical radiographs will show whether pulp has remained vital or not. * Examination of amalgam restorations - Amalgam restorations are evaluated for • Amalgam blues • Proximal overhange. • Marginal gap or ditching. • Voids • Fracture lines • Interface lines • Improper anatomical contours.
  16. 16. • Marginal ridge incompatibility • Improper proximal contacts • Recurrent caries. Examination of cast restorations - Is evaluated clinically in the same manner as amalgam restorations. - If restorations are not satisfactory or carrying tissue harm it is classified as defective and considered. For recontouring, repair or replacement. Examination of tooth colored restorations Any improper proximal contact, contour, overhanging proximal margin, recurrent caries then the restoration is considered defective. If dark marginal staining or discoloration present, esthetically displacing then replacement. Examination of Periodontium Clinical examination - Gingival color and texture is examined as they are important indices of periodontal health. - Depth of gingival sulcus around each tooth is determined. Presence of pocket (Sulcus depth greater than 3mm) or haemorrhage or exudates indicates periodontal disease. - Evaluate presence of bifurcation or trifurcation involvement – affects long term prognosis of the tooth. - Note areas of gingival recession - Teeth should be evaluated for mobility -> as it indicates significant loss of bone support which could affect subsequent operative treatment. Radiographic examination - Bitewing radiographs help in assessing bone levels. - Radiographs aid in determining the relationship between the margins of existing or proposed restorations and the bone. Examination of occlusion
  17. 17. - The static relationship of the teeth in intercuspal position (ICP) should be examined to determine the horizontal and vertical overlap of the anterior teeth, together with the relationship of posterior teeth. - The way in which the teeth, function against each other in forwards, backwards and lateral movement of the mandible should be examined. Examination should also look for “Plunger cusp” which is a pointed cusp plunging deep into the occlusal plane of the opposing arch. This may result in food impaction or tooth/restoration fracture. Examination of pain (Tooth ache) Field defined pain as “an unpleasant sensation that is perceived as arising from a specific region of the body and is commonly produced by processes that damage or are capable of damaging bodily tissue”. International Association for the study of pain (IASP) defined pain as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. Pulp pain: or pulpalgia, is the most commonly experienced pain in and near the oral cavity and may be classified according to degree of severity and the pathologic process present : 1. Hyper reactive pulpalgia. a. Dentinal hypersensitivity b. Hyperemia 2. Acute Pulpalgia. a. Incipient b. Moderate c. Advanced 3. Chronic Pulpalgia a. Barodontalgia 4. Hyperplastic pulpitis 5. Necrotic pulp 6. Internal resorption 7. Traumatic Occlusion 8. Incomplete fracture
  18. 18. Mildest pulp discomfort, experienced when no inflammation is present; is hyper reactive pulpalgia Quality of pain: Pulp pain are of two varieties a. Sharp, piercing an lancinating a painful response associated with excitation of the A-delta fibres (Myelinated, post conducting and low pain threshold) • Cold stimulates the fast conducting as fibres • This pain usually reflects reversible state. b. Dull, boring, gnawing and extruciating - a painful response usually associated with C- nerve fibres (Unmyelinated, slow conducting and higher pain threshold). Heat usually stimulates the slow conducting (Fibres * This pain usually reflects an irreversible state of pulpitis. • Pulpal and periapical pathosis produce sensations that are described with terms such as - Aching - Pulsing - Radiating - Flashing - Zolting - Electric - Recurrent Duration of pain - Pain of shorter duration, is considered to be reversible pulpitis, whereas when pain is of longer duration irreversibly. - Tooth with pulpal pain that disappears on removal of irritant has shown excellent chance of recovery without the need of endodontic treatment. Inception 1. Mode : Spontaneous or provoked, sudden or gradual, stimulated * Immediate * Delayed
  19. 19. 2. Periodicity: Symptoms have temporal pattern or sporadic or occlusional, recurrent pain. 3. Frequency: Continuous or Intermittant. Intensity of pain 1. Quantify the pain by assigning to the pain a degree of 0 (none) to 10 (intolerable pain) helps to monitor patrents perception of pain throughout the treatment. 2. Mild, moderate or severe. Predisposing factors - Factors that can precipitate the onset of symptoms which may indicate a non-odontogenic cause. - Postural changes : Jaw pain or headache on bonding over, blowing the nose or jogging -> maxillary sinusitis - Time of day - stiffness and pain in jaws and masticatory muscles a waking – TMJ dysfunction. Pain on strenuous or vigorous activity -> pulpal or periapical inflammation. - Hormonal change “Menstrual tooth ache” or recurring hypersensitivity may occur due to increased body fluid retention. Symptom disappears when the cycle ends. Referred pain • Common in advanced pulpitis. Posterior molar pain often referred to opposing quadrant. • Maxillary molars to -> zygomatic, parietal and occipital regions of the head. • Lower molars to -> ear, angle of the jaw or posterior region of the neck. • Localization of pain • Sharp piercing pain can usually be localized and responds to cold. • Dull pain usually referred / spread over a large area responds more abnormally to heat. • Patient may report dental pain that is exacerbated while lying down or bending over. This occurs because of increase in blood pressure to the head, which subsequently increases the pressure on the confined pulp. • Factors which provoke (relieve pain) (IEJ, 1990 by AH. Rowe et al) - On assessment of pulp vitality by A.H. Rowe et al, response to a provoking factor (E.g. on mastication) indicates pulp vitality, but stimulation causing extended severe pain suggests irreversible pulpitis.
  20. 20. - Heat, cold, sweets, percussion, biting, chewing, palpation. Diagnosing toothache. A patient complaining of toothache is most likely to be suffering from one of the following conditions. • Acute Pulpitis • Acute apical periodontitis • Acute apical abscess • Acute periodontal abscess • Chronic pulpitis • Chronic apical periodontitis • Exposed sensitive dentin. • Food packing • Cracked cusp • Pulpitis resulting from caries is most common cause of tooth ache. • Several other conditions of mouth and face may be confused with tooth ache. Example : Maxillary sinusitis. * Pericoronitis * Trigeminal neuralgia • Mandibular dysfunction • Atypial facial pain • Lesions of salivary glands and soft tissue. Acute pulpitis • Severe pain, poorly localized to the tooth • Two clinical presentations * Reversible * Irreversible • Differential diagnosis of reversible and irreversible pulpitis. Reversible Irreversible
  21. 21. 1. History Slightly sensitivity or occasional pain Constant or intermittent pain 2. Pain Momentary and immediate, sharp in nature and quickly dissipates after removal of stimulus. Continuous, delayed onset, throbbing, persists. For minutes to hours after removal of stimulus 3. Location of pain May be localized and not referred Pain not localized it localized only after peripheral involvement. Pain is refe….. 4. Change of posture No difference Pain increases 5. Thermal test Responds Marked prolonged. 6. E.P.T Early response Early, delayed or mixed response 7. Percussion Negative Negative in early stages later positive when periapex involved. 8. Radiography Negative May show widening of periodontal ligament space. Acute apical Periodontitis - Classical presenting sign is that patient presenting indicating which tooth is causing pain, whereas patient with acute pulpitis holds their hand to the side of their face. - Tenderness on percussion - Pulp contains pain nerve endings only but the periodontal ligament contains both pain and pressure sensitive nerve endings. Acute apical abscess - Patient presents with a large tender swelling, either intra orally or on the face. - Sometimes patient presents before swelling has appeared or after it has spontaneously burst or subsided. - Patient may feel unwell and have a temperature. - Pulp usually gives a non vital response.
  22. 22. Acute Periodontal abscess - Forms at the base of deep periodontal pocket, presentation similar to acute apical periodontitis or acute apical abscess but tooth may still be vital. - In some cases infection arising from deep pocket meets with infection arising from necrotic pulp ->perio -> endo lesion (Poor prognosis). Chronic Pulpitis - Produced mild, poorly localized pain which sometimes comes and goes over a period of weeks or months. - If untreated, pulp becomes non-vital and symptoms of chronic pulpitis disappears - Responds to vitality test. - Not tender or percussion Chronic apical periodontitis. - Symptomless condition, may feel mild pain on biting. - Vitality test negative. - Slightly tender to percussion (Dull note) - Main diagnostic sign - is peri apical radio lucency seen. - When sinus is present - gutta percha point will show approaching the apex of the relevant tooth on the radiograph. - In all above condition, no radiographic changes in periapical tissues except a slight thickening of apical periodontal space with acute apical abscess. - In chronic state, apical granuloma not infected -> chronic inflammatory response to toxins leaching from apex of tooth with necrotic pulp. - These toxins are diluted because natural limit to size of chronic periapical granuloma - Beyond this size, toxins are too dilute to stimulate osteoclastic action. - A peripheral granuloma, highly vascularized repair tissue, because after root canal therapy granuloma replaced by normal bone. - Chronic apical granuloma
  23. 23. May become infected or may become And flare up into an cystic, which also Acute apical abscess can become infected (Phoenix abscess) and flare up into A.A.A. Exposed sensitive dentin - May result from gingival recession or surgery producing exposed root surfaces, failing restoration or caries exposing dentine to oral fluids. - Sensitivity to hot, cold. Sweet. Food & drink. - Poorly localized Food packing Contact point not tight due to teeth drifting apart, poorly contoured restoration. Food wedges between the teeth and causes periodontal pain. DIAGNOSTIC AIDS IN CARIES The coronal carious lesion starts as a clinical undetectable sub surface demineralization with further progression, it will eventually become clinically detectable. Apart from, for the occult fissure penetrating deeply into the dentin, dilemmas in clinical detection and registration arise not with the advanced lesion, but primarily with the early lesion (confined to out enamel), the non-cavitated lesion of dentin, recurrent caries (around the margins of restoration) and sub gingival root caries. According to Pitts (1997), the ideal method or toot for diagnosis of carious lesions would be non-invasive and provide simple, reliable, valid, sensitive, specific and robust measurements of lesion size and activity and be based on biologic processes directly related to the carious process. Diagnostic tools. Some decades ago, visual diagnosis (light and mirror) and probing, supplemented by bitewing radiographs were the only roots available for clinical diagnosis of caries. These tools detected the presence of cavitation rather than measuring the disease as a continuous process that starts from the appearance of microporosity as a result of demineralization leading to cavitation.
  24. 24. The radiographic image of occlusal fissure is complex and is such that caries would only be visible when it affects the base of the fissure. Occlusal caries progresses along the fissure walls, finally reaches dentin. Old trends 1. Visual detection Combination of light and minor Most commonly applied method Sensitivity is low, specificity high Major shortcoming is that this method is very limited for detecting non-cavitated lesions in dentin on the posterior approximal and occlusal surface. 2. Tactile sensation with explorers Caries is diagnosed if tooth meets the ADA criteria of softened enamel that catches an explorer and resists its removal or allows the explorer to penetrate proximal surface under moderate to firm probing pressure. In recent years, it has been shown that a sharp explorer may cause cavitation of an intact surface enamel with sub surface demineralization (Bergnan and Linden 1969, Quist and Thylstrup 1987) and could force cariogenic bacteria into depth of lesion. 3. Radiographs Bitewing and periapical radiographs commonly used. Also occlusal radiographs, panoramic radiographs are sometimes indicated The diagnostic yield that could be gained from a radiograph outweighs the potential adverse effects of exposure to radiation. Radio graphs have some limitations • 2 dimensional representation of 3 - dimensions object. • Interpretation would produce certain false - positive and false negative diagnosis • Does not diagnose earliest stages of lesion. • Approximal caries (secondary) on more apical part of restoration may not be detected. • Non cavitation carious lesion on the root are difficult to diagnosis.
  25. 25. • The only way to guard against these limitations is to continually correlated clinical and radiographic findings. 4. Temporary elective tooth separation and impression Using wedges and elastics Helps in assessing whether radiographically detectable approximal enamel and dentin lesions are cavitated. Combined with localized impression allows a more sensitive diagnosis of cavitation. 5. Caries detector dyes. - Van de Rijke (1991) reviewed the use of dyes in cariology - Used clinically to differentiate between outer carious dentin and inner affected dentin - Outer carious dentin is distinctly stained. - Fluorescent - Fluoros TGA - sodium fluorescent Zyglo 21-22, pyrromethene 556. - Non fluorescent - 1% acid red in propylene glycol - Carsolen green - Lssamine blue - 1% acid red is basically a food dye. - Iodide penetration method for measuring enamel porosity of incipient smooth surface lesion was developed by Brudevold and co-workers. Newer trends 1. Computer – Based image analysis Recently been applied for examination of dental radiographs. Program detects a lesion, and designs its borders, measures and reports the lesions parameters, percent mineralization area and maximal and mean enamel penetration. 2. Quantitative light induced fluorescence (QLIF)
  26. 26. Benedict (1928) first noted fluorescence of organic components of teeth and also the difference in fluorescence between sound and carious enamel using visible light compared with ultra violet light Lesion with depth of only 25 um have been measured. Demineralized area appears as dark region because of loss of intrinsic fluorescence substances (hydroxyapatite crystals and tubules) in demineralized enamel and dentin. Quantitative laser induced fluorescence used organ – ion laser (488 mm). In some studies, fluorescence dye was applied to the lesion to enhance the difference between sound and carious tissues. Currently QLF system uses are lamp filtered to a small band (370 + 80 nm) Uses because • Early caries detection • Monitoring white spot lesion • Evaluation of quality of fissure sealants and dental restorations (red fluorescence indicates micro leakage – porphyrins metabolized by bacteria) • Detection of plaque Limitations • Restricted to smooth surface caries diagnosis. • Should be performed under standardized conditions regarding hydration of tooth • Circular lesion (Mesiobuccal or distobuccal) cannot be detected because optical axis of QLIF has to be oriented Ist molar to tooth surface 3. Electro conductance measurement (ECM) Idea of electrical method of caries detection first proposed by Magitot (1878). Theory: Sound surfaces posses limited or no conductivity, whereas carious or demineralization enamel have measurable conductivity that increases with increasing demineralization. Pincus (1951) first suggested the concept of testing for caries through electrical independence. - Subsequently two instruments were developed in 1980. 1. Vanguard electronic caries detector 2. Caries meter L
  27. 27. Both instruments measured the electrical conductance between the tip of a probe placed in the fissure and a connector attached to an area of high conductivity (example gingiva and skin). In vanguard ECD, the recording dial shows number 0-10 and a picture of a “face” that smiles up “……….” to value of 5 (caries –ve) and frowns “………..” when the value is greater than 5 (Caries +ve) A new instrument electronic caries monitor is currently being evaluated. 4. Digital fibre optic transmillumination (DIFOTI) Illumination is delivered by means of fibre optics from a light source to tooth surface. Resultant changes in light distribution as light transverses the tooth are recorded as image for analysis. FOTI: designed for detection of proximal caries (Friedman and Marcus, 1970). Decayed tooth material scakkers light more strongly, thus has lower index of light transmission than sound tooth structure. DIFOTI – by combining FOTI and digital CCD camera. DIFOTI can detect incipient and recurring caries before they are visible on radiographs. 5. Endoscopic filtered fluorescence (EFF) Endoscopic examination with either white light or filtered fluorescence excited by blue cutting light was performed by long bottom and Pitts (1990) Their studies showed that with both methods initial proximal lesions appear darker than surrounding areas. 6. Alternating current inpedence spectroscopy technique (ACIST) A more sophisticated approach to lesion detection and measurement is to characterize the electrical properties of the tooth and lesion by using ACIST which scans multiple frequencies. The ACIST is new and has been evaluated only to a limited extent on whole carious teeth. 7. Magnetic resonance micro imaging (MRM) Significant value in detection of early changes in mineralized dental tissue. Non invasive and non destructive
  28. 28. Its use allows a specimen to be reimaged after further exposure to a clinically relevant environment. When a magnetic field is applied, the nuclear spins align in a finite number of allowed orientation, if these orientations are perturbed by a pulse of radiofrequency energy, this energy is absorbed and then retransmitted. It is this retransmitted energy that is detected. 8. Ultra sonic Imaging Ultrasonic imaging was introduced by Ngo et al (1988) as a method for detecting early caries in smooth surface. They showed (in vitro) that artificial enamel lesions less than 57% of sound enamel mineral content in the body of the lesion could be differentiated acoustically from intact enamel on the basis of amplitude changes. The authors concluded, however, that the method is not yet sensitive enough to detect changes of shallow caries lesions in vivo. 9. DIAGNODENT. Tooth surface is illuminated with pulses of red laser light, and fluorescence emitted from the surface is analyzed and qualified. Caries lesions alter the amount of fluorescence that can be seen as increased needing. A valuable adjunct for occlusal caries detection in permanent teeth (Lussi et al 1999) Commercial development is chairside, batteria powered Diode laser fluorescence device. This unit emits light at 655 non wave length from fibre optic bundle directed onto occlusal surface. A second fibre optic bundle receives the reflected fluorescence light beam and changes caused by demineralization are displayed as numerical value on the monitor. A laser probe is used to scan over the fissure area in sweeping motion. Numerical value * 5 – 25 indicate initial lesion in enamel * Greater than 25 – early dentinal caries * Greater than 35 – advanced caries. - Limitations • Depth of penetration of light limit to 2 mm. • Detects only occlusal involvement not approximal surfaces.
  29. 29. 10. Stray – Field Imaging (STRAFI) - is a magnetic resonance microscope, that shows outer and inner contours of the teeth. - The resolution in MR imaging is provided by change of magnetic field. - A non destructive way to examine root canal morphology. 11. Radio Visuography (RVG) - Digitizes ionizing radiation and provides an instantaneous image on a video monitor thereby reducing radiation exposure by 80%. - Has a fibre optic intra oral sensor. - Advantages • Elimination of x-ray sensor. • Significant reduction in exposure time • Instantaneous image display. - Has 3 components 1. “Radio” a hypersensitive intra oral sensor and a conventional x-ray unit. 2. “Visio” consists of video monitor and display processing unit. 3. “Graphy” component – high resolution video printer that instantly provides a hard copy of screen image. - Resolution is slightly lower then conventional films, however can be improved through enhancement procedures. 12. Caries activity tests - Helps in identifying high risk groups and individuals. 1. Lactobacillus colony count tests • Introduced by Hadley in 1933, popularized by jay. • No of lactobacillus colonies in saliva are related to caries susceptibility 2. Colorimetric Snyder test • Measures the ability of salivary m.o. to form organic acids from a CHO medium, which contains indicator dye, Bromocyes of green. • Rate of color change from green to yellow is indicative of the degree of caries activity.
  30. 30. 3. Swab test • Developed by Grainger 1965. • Swab is incubated in the medium for 48 hrs, change in pH is indicative of degree of caries activity. 4. Salivary Buffer capacity. • Volatile bicarbonate onion is the important component of salivary buffer system. • Saliva samples requiring less than 0.45 ml of standard Hcl have low buffer capacity and those requiring 0.45 ml or more have high buffer capacity. 5. Streptococcus mutans level in saliva. - Measures the number of streptococcus mutan colony forming units per unit volume of saliva. 6. Enamel solubility test • Glucose is added to saliva containing powdered enamel. • Thus organic acids are formed, which decalcify the enamel, resulting in increase in soluble calcium which is a direct measure of degree of caries susceptibility 7. Salivary reductable test • Measures the activity of reductable enzyme present in salivary bacteria. 8. Alban Test • Simplified form of Synder Test Measurement of salivary flow rate • Easy to measure at the chair side. • Patient chews paraffin wax to stimulate saliva for 1 min and spits it into a measuring cylinder. • Stimulated salivary flow rate a expressed in milli litres (ml) per minute. • Normal rate in adults = 1-2 ml/min. Xerostomia = 0.7 - 0.1 ml / min. DIAGNOSTIC AIDS IN ENDODONTICS 1. Visual and Tactile inspections • Examination of hard with soft tissue for 3 C’s : Color, contour and consistency
  31. 31. • Soft tissue Color: Normal color of gingiva is pink, change from this is easily visualized in inflammatory conditions. Contour: change in normal contour (Scalloped gingiva) occurs with a swelling. Consistency: on inspection (gingiva) appears health, firm, resilient, while a soft, fluctuant or spongy tissue is move indicative of a pathological state. Hard tissue Color: Normal teeth show life like translucency and sparkle that is missing in pulpless teeth which appear more or less opaque. Contour: examination of contours of effected teeth, such as fractured teeth, wear facets, improperly contoured restorations or altered crown contours as these factors can have marked effect on the respective pulps. Consistency: change in consistency is related to presence of caries, external and internal resorption. - Presence of sinus tract opening into gingival crevice and deep pockets are discovered by tracing with a gutta percha cone. 2. Palpation • Simple test done with finger tip using light pressure to examine tissue consistency and pain response. • Helps to determine the following a. Whether tissue is fluctuant and enlarged sufficiently for incision and drainage. b. Presence, intensity and location of pain. c. Presence and location of edenopathy d. Presence of bone crepitus. • When posterior teeth are infected, sub maxillary lymph nodes are usually involved, anti teeth submental lymph nodes involved. • When infection confined to pulp and not progressed into periodontium palpation is not diagnostic. • Palpation, percussion, mobility and depressability test check the integrity of attachment apparatus and not the condition of pulp. 3. Percussion
  32. 32. • Tooth is struck with a quick, moderate blow initially with low intensity by the finger, then with increasing intensity by the finger, then with increasing intensity by using handle of an instruments. • A positive response to percussion indicates not only the presence of inflammation of periodontal ligament but also the degree of inflammation. • Periodontitis can also occur around tooth with vital pulp as in rapid ortho movement, recently placed restoration in hyper occlusion. • Chronic peri apical inflammation often yields negative result with percussion. • Dull note – signifies abscess formation Sharp note – denotes inflammation (Ingle) 4. Mobility and depressability tests • Rationale of mobility test is to evaluate the integrity of the attachment apparatus surrounding the tooth. • Test consists of moving the involved tooth facio-lingually using handles of two instruments or using two index fingers. • Test for depressibility is performed by applying pressure in an apical direction on the occlusal/incisal aspect of tooth and observing vertical movement if any. When this exists chances for retaining the tooth ranges from poor to hopeless. • Grades of mobility (Grossman & Cohen) Grade I (First degree) - Less than 1 mm of horizontal movement. Grade II (Second degree) – Lateral (Horizontal) movement of around 1 mm. Grade III (Third degree ) – greater than l mm of horizontal movement accompanied by vertical depressability Grades of mobility (miller) 0 - Non mobile / mobility within physiological limits 1 - Mobility within range of 0 – 0.5 mm 2 - mobility with 0.5 – 1.5 mm with lateral movements. 3 - Mobility more than 1.5 mm with lateral movements and can be depressed into the socket
  33. 33. • Endo treatment should not be carried out on teeth with third degree mobility unless mobility is reduced by drainage of acute apical abscess. Mobilometers • are electronic devices / gad gets, which aid in determining tooth mobility • Apparatus consists of two electrodes (Prays which hold facial and lingual surface of the teeth. • Degree of mobility tested is reflected as a numerical reading. 5. Periodontal examination • Consists use of a blunt celibrated probe to explore the integrity of gingival sulcus around each tooth. • A significant pocket if present in the absence of periodontal disease it increases the probability of presence of vertical treatment. • To distinguish disease of periodontal origin from pulp origin, thermal and EPT along with PDL probing are essential. 6. Radiographic examination • Radiograph is 2 dimensional image of 3 – dimensional tooth because radiographic strategy should involve the exposure of 2 films at the some vertical angulation but with 10-15 degree change in horizontal angulation (SLOB rule) Radiographs can contain information on 1. Presence of caries that may involve or threat on to involve the pulp. 2. May show the number, cause, sharp length and width of root canals. 3. Presence of calcified materials in the pulp chamber or root canals. 4. Resorption of dentin originating with in the root canal or from the root surface. 5. Calcification or obliteration of pulp cavity 6. Thickening of PDL 7. Resorption of cementum 8. Nature and extent of periapical and alveolar bone destruction.
  34. 34. Radiographic interpretation - A single root canal should appear tapering from crown to apex, sudden change in appearance of canal from dark to light indicates that the canal had bifurcated or trifurcated. - Horizontal root and may be confused radiographically with linear patterns of bone trabeculae. Lines of bony trabecular extend beyond the border of the root while root and often cause thickening of PDL. - Radiographic differentiation of external and internal resorptoin. Internal R : have sharp smooth margins and the pulp “disappears” into the lesion. External R : margins not smooth and pulp appears to pass through the lesion unaltered. - Shift method can be used to differentiate internal and external resorption, here the position of internal resorption is unaltered lesions of cancellous bone only are not seem in radiograph until the cortical bone has been reached or penetrated. Radiographic misinterpretation Presence of periapical radiolucency on a tooth does not indicate a diseased tooth. In many instances an area of rare faction on the root apex may be the super imposition of an image on the apex. This phenomenon may be seen, where anatomy is normal as in maxillary sinus, incisive and mental foramen, medullary space, traumatic bone cysts etc. A number of pathological changes in and near the alveolar process may be mistaken for true periapical lesions 1. Non-odontogenic cysts : Lamina dura is intact in all non-odontoblastic cysts i. Globulomaxillary cyst lesion appears inverted pear shaped ii. Midline palatal cyst lesion occurs in midline. 2. Apical scar : History of apical surgery intact lamina dura 7. Xeroradiography • Derived from Greek word “Xeros” which means dry.
  35. 35. • Uses a rigid aluminium / selenium coated photoreceptor plate. Plate is electrically charged, placed in a water proof cassette, positioned in the mouth and exposed to x-rays at a lower level of radiation (25 secs.) • Plates may be reconditioned, recharged and used repeatedly. Advantages i. Sharper, cleaner and finer details of images. ii. Radiation dose reduce iii. Pronounced edge enhancement. 8. Digital substractions radiography - Used to detect the progress of caries from an incipient lesion, through the DEJ. - Assessment of healing or expansion of periapical lesion after root canal therapy. - Measured the changes in the density of the lesion. - This is an image enhancement method, resulting in the area under focus being clearly displayed against a neutral gray black back ground i.e. required areas are enlarged against the entire background. VITALITY TESTS 1. Thermal tests • Heat • Cold • Heat / cold tests are performed by placing the stimuli on inciso-labial (anterior) surface or occluso-buccal (Posterior) surface. • Cold Test - Includes air blast, cold water bath, ethyl chloride sticks of ice, carbon dioxide ice sticsk (-78oC) (ehrmann) - Ethyl chloride and cold water bath are more common, kept in contact with the tooth. For 5 seconds or until patient feels pain. - Disadvantage with carbon dioxide Snow -> causes infarction lines in enamel. - Aerosol of dichloro – difluoromethane was introduced to substitute carbon dioxide snow
  36. 36. - Heat test - Can be performed with hot air, hot water, hot burnisher, hot gutta percha, hot compound polishing of crown with a rubber cup. - Most commonly gutta-percha stick used. - Preferred temperature upto 150oF according to Rowe et al (1990) or 65.5oC. - Responses to thermal tests. Sensory fibres of pulp transmit only pain whether pulp has been cooled or heated. 1. No response – non-vital pulp is indicated. 2. Mild to moderate degree of awareness of slight pain that subsides within 1-2 sec after stimulate has been removed – normal. 3. Strong, momentary painful response that subsides within 1-2 secs after stimulus is removed – reversible pulpitis. 4. Moderate to strong painful response that lingers. For several seconds or longer after stimulus has been removed – irreversible pulpitis • False positive response can occur -> excossive calcification, immature apex, recent trauma, premedication. 2. Electric pulp tests • EPT is designed to stimulate a response of sensory fibres within the pulp by electric excitation. • Disadvantages of EPT 1. Cannot be used on patients having cardiac pace maker. 2. Does not suggest the health or integrity of the pulp, simply indicates the presence of vital sensory fibres with in the pulp. 3. Does not provide any information about vascular supply of pulp, which is the true determinant of pulp vitality. • Analytic technology pulp tester widely used. • First lip clip is attached, electrode is coated with viscous conductor (tooth paste) and applied on the middle third of facial surface of the crown. Current flow should be increased slowly until the patient feels a tingling sensation. • Thicker enamel – more delayed response
  37. 37. • EPT false readings 1. A false positive response means pulp is necrotic, patient feels sensation in tooth. Reasons • Electrode or conductor contact with metal restoration or gingiva. • Patient anxiety. • Lique faction necrosis may conduct current to attachment apparatus. • Failure to isolate and dry the teeth (saliva) 2. False negative response means that pulp is vital, but patient does not respond, Reasons • Patient heavily pre medicated with analgesics, alchohol or tranquilizers • Inadequate contact will electrode or conductor and enamel. • Recently traumatized tooth • Excessive calcification of canal. • Recently erupted tooth with immature apex. • Partial necrosis 3. Test Cavity • Performed when other diagnostic methods have failed. • Test cavity is made by drilling through enamel dentin junction of unanaesthetised tooth. • Sensitivity or pain felt is an indication of pulp vitality. 4. Anaesthesia test • Performed when usual tests have failed to enable one to identify the tooth. • Objective is to anaesthetize a single tooth at a time until the pain disappears and is localized to specific tooth. 5. Laser Doppler Flowmetry • LDF was introduced (first in 1972 to determine blood flow in retina of rabbits of Riva, Ross and Bendek) as a non-invasive method to measure the blood flow.
  38. 38. • This technique uses a helium neon laser light beam that is directed into the tooth. • Light that contacts a moving object is Doppler shifted, and a portion of that light to photodetector, and a signal is produced • As red blood cells represents the majority of moving objects within the tooth, measurements of back scattered light serves as an index of PBF. • Disadvantages is measurements are sensitive to arxe facts such as movement or pressure, equipment is bulky and costly. 6. Pulse oximetry • Oximetry refers to determination of percentage of oxygen saturation of circulating arterial blood. • Matthes – father of oximetry (1934 – 1944) • Millikan coined the term “Pulse oximetry” • Probe sensor consists of two light emitting diodes, one to transmit red light (640 mm) and other to transmit infra red light (960 mm) and photo detector on opposite side of vascular bed. • Well oxygenated blood appears bright red (81%) 7. Liquid crystal testing • Howell et al (1970) employed the color change of cholisteric liquid crystals applied to surfaces of the teeth, as diagnostic modalities • Changes in temperature or pressure alter the pitch and period of helical structure, so new colors are produced. • Pulpless teeth exhibited lower surface temperature than those with vital pulp. 8. Hughes Probeye camera • Capable of deteching temperature changes as small as 0.1oC. • Used to measure pulp vitality experimentally Ultra sound real time imaging • technique that helps in differential diagnosis between cysts and granulomes by revealing the nature of content of bony lesion.
  39. 39. • It widely used in medicine, based on the phenomenon of reflection of ultra sound waves (echoes) at interfaces between tissues that have different acoustic properties. • Hypoechoic or transonic – low echo intensity anechoic – no reflection of echoes occurs in any area filled with fluid. • Hyperechoic – high echo intensity (Bone) • Cystic lesions -> hypo echoic, well contoured cavity, surrounded by reinforced bone walls, filled with fluids, no evidence of internal vascularization on color power Doppler examination • Granuloma : Poorly defined lesion, could be hyper echoic or both hypo & hyper echoic, exhibiting rich vascular supply on color Doppler examination Computerized tomography • Blends concept of thin laser radiography with the computed image. • Techibena has reported use of CT in endodontics • Possible to determine bucco-lingual and mesio-distal widths of teeth. • Presence or absence of root canal filling materials and posts. • Carious lesions, extension of maxillary sinusitis and proximity to root apices. MAGNETIC RESONANCE IMAGING • Magnetic fields and radiographic waves are used to generate high quality cross sectional images of the body. • Can distinguish blood vessels and nerves from surrounding soft tissues. • Disadvantages : Not to be used in patients with cardiac face makers metallic restorations / ortho appliances, aneurysons. COMPUTERIZED EXPERT SYSTEM • Reported by John Firriola • Comendex (CES) used for diagnosis of selected pulpal pathosis which is :- - Normal pulps - Reversible pulpitis - Irreversible pulpitis due to hyper occlusion
  40. 40. - Irreversible pulpitis - Necrotic pulp - Infection due to endodontic failure • Diagnostic case focks are obtained and this data entered into the computer. The computer checks and gives out the diagnosis. Tuned aperture computed tomography (TACT)  New type of imaging device that decreases the super imposition of overlying anatomical structures.  TACT system uses digital radio graphic images and the TACT soft ware correlates the individual images of a subject into a layering of images that can be viewed into slices.  TACT image is composed of series of 8 digital radiographs that are assimilated into one reconstructed TACT image.  Used in visualization of canals in human molars.  Evaluating primary simulated recurrent dental caries and simulated osseous defects.  New tool to diagnosis external root resorption at an earlier stages.  Disadvantage : Slice obtained were 1.25 mm thick which might be too thick and many of the lesions might have been missed. Infrared thermography • Alterations in the temperatures of diseased bodily structures have been detected with sophisticated infrared thermographic equipment. • It has been assumed that teeth with vital pulps would have higher surface temperature than those with necrotic pulps. Diagnosis of cracked tooth syndrome. • Cracked tooth syndrome is defined as the incomplete fracture of natural crown of a premolar or molar tooth. • Gibbs n 1954 – termed it “Cuspal fracture odontalgia”
  41. 41. • Ritchey et al 1957 - reported various cases of incomplete fractures with subsequent pulpitis • Cameron 1964 – termed “cracked tooth sydrome”. • Also called “green stick fracture” or “split tooth syndromes”. • Incomplete cracks are either limited to the crown or may include root also. Combined fractures are called “split root syndrome”. 1. Transillumination test: Light from fibre optic is applied from buccal surface to illuminate the tooth to detect fractured lines when present. 2. Biting test – an orange wood stick, or cotton wood stick or rubber wheel or tooth sloth is placed on occlusal (incisal aspect of the tooth and patient is asked to bite. Sharp pain on chewing of hard or tough food is very important diagnostic evidence of cracked tooth. This type of pain is triggered as the pressure is released. 3. Staining: remove the filling from suspected tooth and place 2% Iodine in the cavity preparation. Iodine stains the fracture like dark methylane blue dye also used. • Mix a dye with ZOE and place it is cavity preparation after filling has been removed. Dye will seep out and color the fracture line. • Have a patient chew disclosing tablet after taking out filling in suspected fracture tooth. Line will be stained. GUTTA PERCHA POINT TRACING WITH A RADIOGRAPHY • Purpose: can localize the endodontic lesion to the specific tooth. • Aids in differential diagnosis between a periodontal and an endodontic lesion. • Technique: place a gutta percha point through the sinus / fistula tract and take a radiograph. Treatment planning A treatment plan is a carefully sequenced series of services designed to eliminate or control etiologic factors, repair existing damage, and create a functional, maintainable environment.
  42. 42. Treatment plan sequencing • Urgent phase • Control phase • Re-evaluation phase • Definitive phase • Maintenance phase. Urgent phase A patient presenting with swelling, pain, bleeding or infection should have these problems managed as soon as possible and certainly before initiation of subsequent phases. Control phase Is meant to 1. Eliminate active diseases such as caries and inflammation. 2. Remove conditions preventing maintenance 3. Eliminate potential causes of disease. 4. Begin preventive dentistry activities. • Goals of this phase are to remove etiologic factors and stabilize the patients dental health. • Example : of control phase treatments include 1. Extractions 2. endodontics 3. Periodontal debridement and scaling 4. Occlusal adjustment 5. Caries removal 6. Replacement or repair of defective restorations 7. Use of caries control measures. * Prevention and management of caries Chemical - use of anti microbial agents to alter oval flora and administration of topical fluoride. Surgical - Removal of diseased tooth structure and replacement with restorative material
  43. 43. Rehavioral - help the patients develop skills, knowledge and knowledge to alter deleterious dietary intake and improve oral hygiene Mechanical - mechanical alteration of tooth structure at high risk (example sealants) Dietary - alterations of the character of the diet Other – stimulation of salivary flow through increased chewing, alteration of medications and use of artificial saliva. *Re-evaluation phase • The holding phase is a time between control and definitive phases that allows. For resolution of inflammation and time for healing. • Home care habits are reinforced, motivation for further treatment is assessed, and initial treatment and pulpal responses are re-evaluated before definitive care is begun. * Definitive Phase This is the corrective phase which includes endodontic, periodontic, orthodontic – oral surgical and operative procedures before fixed or removable prosthodontic treatment. All teeth to be restored with large or east restorations should have pulpal / periapical evaluation. If indicated they should have endodontic treatment before restoration is completed. Endodontically treated teeth with no evidence of healing, or has inadequate fill should be evaluated for retreatment. Maintenance phase Regular recall examinations that 1. May reveal the need for adjustments to prevent future breakdown 2. Provide an opportunity to reinforce home care. 3. Frequency of recall examination depends on patients risk for dental disease. 4. Low risk patients -> 9-12 month interval High risk patients -> 3 – 4 months interval. CONCLUSION
  44. 44. Proper diagnosis and treatment planning play a critical role in the quality of dental care. Each patient must be evaluated individually in a through and systematic fashion. After the patients condition is understood and recorded, a treatment plan canbe developed and rendered. Examination, diagnosis, and treatment planning are extremely challenging and rewarding for both the patient and the dentist if done thoroughly and properly with the patients best interest in mind. REFERENCES 1. Operative Dentistry (4th edition) By Sturdvent) 2. Endodontics (5th edition) –Ingle and Bekland 3. Pathways of pulp (8th edition) – Cohen and Burns 4. Endodontic Practice – Grossman 5. The dental pulp (3rd edition) Samuel seltzer J.B. Bender 6. Endodontic therapy (4th edition) Wiene 7. Principle and Practice of endodontics – Weltons Torabinejad 8. Color Atlas of Dental Medicine – Endodontology – Rudolf Beer, Baumenn, Kin. 9. Color Atlas of endodontics – William T. Johnson 10.Pickards manual of operative dentistry (8th edition) – Kidds, Smith and Watson 11.Ultra sound real time imaging in differential diagnosis of peri apical lesion – E.Cotti et al (IEJ. 36, 556-563, 2003) 12.Pulse oximetry a diagnostic instrument in pulp vitality testing – A.K. Munshi, Amitha M. Hegde (J. Clin. Ped. Dent. 26(2), 141-145, 2002) 13.Laser Doppler Flowmetry measurements of pulpal blood flow and severity of dental injury – R Enshoff et al (IEJ, 37, 463-467, 2004) 14.Diagnosis of external root resorption using TACT – Nance R.S., Tyndoll D (Endo dent. Troum 200, (16), 24-28) 15.Quantitative light induced fluorescence (QLF) potential method for dental practitioner – Roswitha Heinniel – Weltzein (Quint. Int. 2003, 34-38, 181-188) 16.Diagnosis, therapy and prevention of cracked tooth syndrome – Werner Geurtsen et al (Quint. Int. 2003, 34, 409-417).

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