Diagnosis in Endodontics

1. DIAGNOSIS IN
ENDODONTICS
-By
Dr.Manjiri Honap
Department of Conservative
Dentistry and Endodontics

2. Learning Objectives
Diagnosis
Diagnostic method
Medical history
Dental history
Subjective symptoms
Clinical observations
Clinical tests

3. Diagnosis
‘The art and science of detecting deviations
from health and the cause and nature there
of’
Glossary of Endodontic terms. 7th ed. Chicago: American
Association of Endodontists;2003

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

5. Dental history
Chief complaint & its history
When was it lastrestored?
Pulp capping/ Pulpotomy/large
restoration in the same
Sharp blow/accident
Swelling/ gumboil
Drainage

6. Subjective symptoms
Is the pain stillpresent?
What type? (Sharp/dull)
Throbbing?
Intermittent/Continuous?
Aggravated by: cold, heat,pressure,
mastication, lying down, sweet, sour?
How long does itlast?

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

8. Palpation
Vestibular region: apical region of theroot
tips
Tenderness, swelling, fluctuation,
hardness, crepitation
Tip of indexfinger

9. Percussion test

10. Periodontal probing
Narrow isolated probing defects:
Sinus- like trap followingperiapical
pathosis
Vertical groovedefect
Crackedteeth
Vertical rootfractures
External rootresorption

11. Tests for Cracked Tooth
Syndrome
Transillumination
Fiberopticlight
Coronal cracks/ vertical rootfractures
Minimal backgroundlighting
Light placed on varied surfacesof
coronal tooth structure/ root after flap
refection

12. Dye staining
Dye penetrates fractureline
Demonstratesfractures
Apply – internal surfaces ofcavity
preparation/ access opening
Iodine/ methylene bluedye

13. Bite test
Wooden stick-opposing teeth
Toothslooth
Patient bites down & pain
elicited upon release

14. Pulp tests
*Ideal technique: non invasive, painless,
standardized, reproducible, reliable,
inexpensive, easily completed & objective
*Chambers. 1982
Pulp sensibility tests
Thermal tests
Electric pulp tests
Test cavity
Pulp vitality tests
Laser doppler flowmetry
Pulse oximetry

15. Clinically Normal pulp
• I m m e d i a c y, i n t e n s i t y, &
d u r a t i o n o f r e s p o n s e
• Mild to moderate - transient responseto
cold & electrical stimuli
• Response subsides in few secondson
removal of stimulus
• Do not usually respond to heattests

16. Reversible pulpitis
Thermal stimuli (cold)- sharppain
Subsides as soon as the stimulusis
removed/ in few seconds

17. Irreversible pulpitis
Thermal changes (cold): sharp pain ,dull
prolonged ache- last upto an hour or so

18. Pulp necrosis
Significant relation between lackof response
& pulp necrosis
No response with EPTs & thermaltests

19. Thermal tests
Often inappropriately referred toas
‘Vitality tests’
More reliable thanEPT
Inexpensive & easy-to- useequipment
Patient’s painreproduced

20. Thermal tests- Rationale
Sensory response: not bytemperature
changes in receptors
Hydrodynamic movement offluid:
dentinal tubules- A fibers
Cold- faster A fibers: sharp localized
pain
Heat- slower C fibers: dull long lastingpain
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010

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

22. Cold tests
Ice sticks
0oC temperature
Not accurate: adult posteriorteeth
Secondary/ reparative dentindeposition
Testing under crowns/splints
Application- 5s or untilpain, Easy to use &
rapidresults
Disadvantage: less effectivestimulation
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010

23. Cold tests
Refrigerant sprays
Dichlorodifluoromethane(DDM)
Tetrafluoroethane(TFE) Green Endo-
Ice(-26oC)
Propane butane mixture(PBM)
Propane , Butane Isobutane - Endo frost-
50oC
Ethyl chloride spray – Chloroethane --
12.3oC less effective than dry ice

24. 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 directapplication
Rapid response: <2s
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010

25. Cold tests
Cold water bath
Tooth/ group of teeth : isolatedwith
rubber dam
Iced water syringed ontotooth
Effective: simultaneous bathing ofentire
crown
Effective with full coveragerestorations
Better than ice sticks & no
armamentarium than rubber dam
Timeconsuming

26. Heat tests
Heat: fluidexpansion- A fibers
Inflamed pulp: C-fibers; lastingresponse
Acutely inflamed/ partially necroticpulp
Low diagnostic accuracy- not usedas
single method

27. Heat tests
Heated GP ( Grossman’s method)
Warmed sticks of GP(120-140oC)
Iight coating of petroleumjelly
GP stick warmed overflame till
glistening
Warmed hand instruments
Difficult to control temperature &
safety problems
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010

28. Heat tests
Frictional heat
Rubber cup-prophylaxis
Buccalsurface
Best, easiest &safest
Goldcrown
Seldom usedtoday

29. Heat tests
Hot water bath
Similar to cold waterbath
Temperature graduallyincreased
Begin with most posterior andproceed
until positive response
Greater thermalchange
PFMcrowns
Time consuming & patientcooperation

30. Heat tests
Electrical heat sources
Touch ‘N Heat/ System B-150oC
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
Castelucci. Endodontics Vol.1

31. Heat tests
Difficult to controltemperature
Concerns of damage to healthy pulp:not
with <5 s application
(Rickoff et al 1988)
Reproducible results notobtained
Lack of response in bulkierteeth
Less consistent stimulus
Limited value: posterior teeth &under
splints , temporary crowns

32. Value of diagnostic tests
Heat: relatively high sensitivity;but least
accurate being the least specific
Cold test: more accurate thanEPT

33. Remember..
Inform patient of the nature oftests
Handsignals
Stimulus removed after 5-6s
Refractory period after coldtest

34. Incisal- anterior & incisal aspect of
mesiobuccal cusp: posterior (Trope &
Debelian 2005)
Ideally be tested on allsurfaces
Several adjacent, contralateral &
opposing teeth tested

35. Pulp sensibility tests
Preferred sequence:
Opposin
g teeth
Presumably
healthy teeth-
same
quadrant
Most
suspiciou
s tooth
• Disease free contralateral control tooth
• Opposing tooth
• Presumably healthy teeth in same quadrant
• Most suspicious teeth

36. 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
Recenttrauma
Immatureapex
RCT teeth: not expected torespond
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010

37. False responses
Extensiverestorations
Pulp protectingbases
High painthreshold
Activation of fixed orthodonticappliances
Psychoticdisorders
Defective EPT device/discharged
batteries/ poor electrical contact

38. 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 necrotictissue,
infected pulp
Breakdown products of localized necrosis

39. False responses
Calcified tooth structure conductingto
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/ youngpatient

40. 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
Pantera et al. 1993

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

42. Limitations
1. Subjective; measure only nerve supply
2.Thermal tests: not effective in substantial
secondary dentin 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)
5.Extensive restorations, pulp recession,
pulp calcification
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010

43. Variations in reading/ False
response
Failure to complete
the circuit
Equipment
problems
Probeplacement
Interfacemedia
Patient related factors
Tooth characteristics
Restored teeth
Dentition
Supporting tissues
Apex maturation
Repeated trials

44. False positive response
Necrotic pulp responds totesting.
Stimulation of adjacentteeth/
attachment apparatus
The response of vital tissue inmultirooted
tooth with pulp necrosis in one or more
canals
Patient interpretation:subjectivity
William T. Johnson. Colour Atlas of
Endodontics

45. False negative response
Vital pulp that does not respondto
stimulation
Inadequate contact
Toothcalcification
Immature apex
Traumaticinjury
Subjective nature of thetests
Elderly patients – regressive neuralchanges
Analgesics forpain
Traumaticinjury

46. Test cavity
Non localized, acute diffuseradiating
pain
Cavity prepared in the tooth:without
anesthesia
Unreliable; response even in necroticpulp
Response unreliable: anxiety
Invasive &irreversible
- Not justified in modernpractice

47. 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

48. Pulse Oximetry
Effective, objective oxygensaturation
monitoring technique - intravenous
anesthesia
Consistently determines the level of blood
oxygen saturation of the pulp - pulp vitality
testing
More sensitive & specific compared to cold
tests & EPT
Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009

49. Ultraviolet light/Fiberoptic
Fluorescent Spectrometry
Fluorescence
Vital teeth fluoresce normally; necrotic&RCT
teeth do not –Foreman
Lighting in the operatory fullysuppressed
Fluorescence from the pulp -substantially lower than
the healthy and decayed dentin fluorescence.
Healthy and decayed dentinpatterns
differentiated
Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2

50. Anesthetic test
L/A: painfularea
Block/ infiltration/intraosseous
Vague location ofpain
Non odontogenic pain:Myocardial
infarction

51. Ultrasound
Compliment conventionalradiography
High resolution, 3D images-inner
macrostructure of the tooth
Detects cracks in a simulated humantooth
Detect vertical root fractures – in both
vital&nonvital teeth
Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2

52. Ultrasonic Doppler Imaging
Blood circulationdetected
Distinguish vital teeth from root- filled teeth:
Promising tool- traumatically injuredteeth
Power Doppler associated with color
Doppler – improved sensitivity to low flow
rates
Non vital tooth
Yoon et al. JOE- Volume 36, No.3, March 2010
Vital tooth

53. RADIOGRAPHY-Little value : assess
pulp status
Presence &extent
of carious lesions
Vital pulptherapy
Calcifications
Resorptions
Periradicular
radiolucencies
Tracingfistulous
tracts
Thickness ofPDL
Periodontal
disease
Root & pulpspace
anatomy
PreviousRCT

54. Diagnosis: never based solely on radiographic
finding

55. Cone Beam Volumetric
Tomography
First used in
dentistry- Mozzo P
et al 1998
Proximityto
anatomic
structures
Rootcanal
anatomy