Take A Good History
Listen to everything the patient wants to
say. Not only will you get useful information,
but you are letting the patient know that you
have time and concern for him or her.
Depending upon the information the
patient supplies, you can often shorten the
History of presenting complain
This is the opportunity for the general practitioner
to let the patient describe a dental problem
as it appears to him/her. You may start
with 'Tell me about your problem' or 'How
can I help?' Allowing time to listen to the
patient in a busy schedule can pay dividends
in reaching the correct diagnosis swiftly and
avoiding embarrassing mistakes. A distressed
patient will be put at ease, and conversation
can then lead into more detailed discussion
HISTORY OF PRESENT COMPLAINT
When did the pain or problem start?
Does anything make the pain better or worse?
Frequency of painful episodes.
Intensity : Dull, Sharp
Duration : Continuous, Intermittent , Prolonged
Response to hot, cold, biting and chewing effects
Patients head and neck soft tissue
examination including TMJ and lymph
Any signs of Swelling
Presence of Sinus Tract
Specific tooth test
SPECIFIC TOOTH TEST
A suspect tooth can be moved gently by finger
and thumb pressure
Any horizontal mobility is then graded
Mobility can result from trauma, root fractures
, periodontal disease and gross root resorption
Grade 01 : 1-2mm Bucco-lingually
Grade 02 : 1-2mm Mesio-distally
Grade 03 : 2-3mm Bucco-lingually and Mesiodistally, vertical depression.
Testing tooth mobility by gently applying lateral forces
between finger and thumb.
Tenderness to palpation:
tooth is moved vertically and
side to side with finger pressure.
Teeth with acute apical
periodontitis will often be tender
when palpated in this manner.
a tooth with a mirror
handle can help identify the kind of
Percussing the tooth occlusallyy :
Percussing the tooth bucally :
Gently percussing a tooth with a mirror handle may
elicit the classical ringing sound that occurs with
replacement resorption (ankylosis).
Pulp sensitivity test
Electric pulp test
Dentine Stimulation test
Selective local anesthesia
Apply the cold test
This is simply done with cylindrically shaped ice sticks.
A good site of cold application is generally the buccal surface
as close to the cemento-enamel junction as possible.
If a metal crown restoration is on the tooth, attempt to apply the
ice on the lingual metal collar, an area where the cold travels
If a tooth has irreversible pulpitis it will either give a prolonged
response, possibly after some delay, or no response.
Transient pain (less than ten seconds) after the application and
removal of ice is normal.
No response may mean the tooth is endodontically
involved, especially if all other teeth respond to cold.
Apply the heat test.
Using a ball of hot gutta percha on the tip of a plastic instrument,
place the gutta percha onto the tooth the same way you would the
ice. Wait approximately 15 seconds between teeth to assess the
possibility of a delayed, but, prolonged response.
Compare the results from other tested teeth. If one tooth gives a
prolonged response, whether immediate or delayed, it is a most
suspicious candidate for endodontics. If the pain is immediately
relieved by cold, the tooth probably needs root canal.
Apply the electric pulp test (EPT).
This test should be used when the hot and cold tests fail to give
clear information on the state of vitality of the tooth. Again, the
information supplied by the electric pulp test must be weighed
against the response from other teeth. the fact that a tooth does not
respond to the EPT has little meaning if all the other teeth also do
not respond, unless of course this is the only tooth with a welldefined area at the apex or is quite tender to percussion.
8. Use bite sticks.
Use bit sticks to check for incipient fractures that are causing pain
to a tooth when under function. By having a patient bite on each
cusp and laterally move the lower jaw, each cusp is subjected to
lateral stresses. If a section of the tooth under a cusp has an
incipient fracture it will often hurt when pressure is applied.
If a fracture does exist, the tooth may not need endodontics if the
fracture does not extend into the pulp. The pain generally
disappears if the fractured portion of the tooth can be cleaved off.
9. Employ transillumination.
Transillumination often confirms the portion of the tooth that has the
fracture. By placing the transillumination light source on the lingual
side of the tooth and turning out the chairside light source, fractures
may be picked up as a dark horizontal line against a light amber
background. Transillumination can sometimes differentiate between
vital and non-vital teeth with the non-vital appearing duller than the
surrounding ones when the light source is applied.
10. Use the binocular microscope.
It is excellent for picking up incipient fractures simply because you
can look at teeth magnified up to 30 X with excellent illumination.
11. Apply selective anesthesia.
It should be applied with an intraligamentary gun.
If specific anesthesia to one tooth makes all pain
disappear for a short time and the effect is
repeatable, the anesthetized tooth is probably
12. Drill a test cavity.
If you believe that a non-vital tooth is causing
symptoms, but cannot confirm non-vitality with
assuredness, a test cavity without anesthesia may
allow entry into the pulp without any pain, thus
confirming your suspicions.
Impacted wisdom teeth diagnosis and treatment planning - the most
common use is to determine the status of wisdom teeth and trauma to the
Periodontal bone loss and periapical involvement.
Finding the source of dental pain
Assessment for the placement of dental implants
Orthodontic assessment. pre and post operative
Caries detection especially in the inter-dental region.
Diagnosis of developmental anomalies such as cleido cranial dysplasia
Carcinoma in relation to the jaws
Temporomandibular joint dysfunctions and ankylosis.
Diagnosis of osteosarcoma, ameloblastoma, osteodystrophy affecting jaws
Diagnosis, and pre- and post-surgical assessment of oral and maxillofacial
trauma, e.g. dentoalveolar fractures and mandibular fractures.
Salivary stones (Sialolithiasis).
CBCT has become increasingly important
in treatment planning and diagnosis in
implant dentistry, among other things.
Perhaps because of the increased access
to such technology, CBCT scanners are
now finding many uses in dentistry, such as
in the fields of endodontics and
orthodontics, as well.
During a CBCT scan, the scanner rotates
around the patient's head, obtaining up to
nearly 600 distinct images. The scanning
software collects the data and reconstructs
it, producing what is termed a digital
volume composed of three dimensional
voxels of anatomical data that can then be
manipulated and visualized with
The bitewing view is taken to visualize the crowns of the posterior
teeth and the height of the alveolar bone in relation to the
cementoenamel junctions. bitewing radiographs are commonly
used to examine for interdental caries and recurrent caries under
existing restorations. Bitewing views are taken from a more or less
perpendicular angle to the buccal surface of the teeth.
The periapical view is taken of both anterior and posterior teeth. The
objective of this type of view is to capture the tip of the root on the film.
This is often helpful in determining the cause of pain in a specific tooth,
because it allows a dentist to visualize the tooth as well as the
surrounding bone in their entirety. This view is often used to determine
the need for endodontic therapy as well as to visualize the successful
progression of endodontic therapy once it is initiated. It can be used in
case of detection hyperdontia& impacted teeth.
Good diagnosis comes from using as many of
the above tools as are necessary to confirm as
solidly as possible your opinion on what should
be done. patients truly appreciate the time you
take to confirm what should be done.
This is especially true when a patient comes in
with a strong feeling that one specific tooth is the
source of the problem, but your diagnosis says
that it is another and after treatment you are right.