DIAGNOSTIC AIDS IN ENDODONTICS.pptx

INTRODUCTION
Diagnosis is arugably the most critical component of all dental
treatment, and endodontics is no exception .
STEDMAN’S MEDICAL DICTIONARY describes clinical diagnosis as “
the determination of the nature of a disease made from the study of the
signs and symptoms of a disease.”
The diagnostic procedure is therefore an important part of treatment
and treatment planning. Collection of information, history, signs and
symptoms, a thorough clinical examination, and objective testing are
mandatory prior to recommending and inititating treatment.
The process of making a diagnosis can be divided into five stages :-
• The patient tells the clinician why the patient is seeking advice
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• The clinician questions the patient about the symptoms
and history that led to the visit.
• The clinician performs objective clinical tests.
• The clinician correlates the objective findings with the
subjective details and creates a tentative differential
diagnosis.
• The clinician formulates a definitive diagnosis.
Most clinician have tried to develop a thorough knowledge
of examination procedures : percussion, palpation,
probing, and pulp testing but still the most basic skill of all
is listening to the patient. All this interpetations along with
answering the ultimate question of why leads to a most
successful diagnosis.
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Without successful endodontics, we are unable to provide
many patients with two of their most important facets –
their ability to smile while displaying their natural teeth
and their ability to use their natural teeth to eat with pain-
free function. A recent study by the American
Association of Endodontists highlighted this, with a third
of participants stating that they would not sell their front
teeth for any amount of money.
American Association of Endodontists: Endodontic fact
sheet
– endodontics and endodontists. 2011.
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REQUIREMENTS OF A DIAGNOSTICIAN
• KNOWLEDGE
• INTEREST
• INTUITION
• CURIOSITY
• PATIENCE
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CONTENTS
1. Endodontic examination
2. Diagnostic testing
3. Laser doppler flowmetry
4. Endodontic radiography
5. Digital imaging for endodontics
6. Ultrasonic imaging
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CONTENTS OF CASE HISTORY
It is a classic form of documentation ranges from clinical sketches to
highly detailed and extended accounts that help in arriving at a
diagnosis and formulation of treatment plan of a person before
treatment.
Name:-to communicate with the patient
-to establish a rapport with the patient d)
Age:- chronological age (date of birth) should be noted to know
whether growth and development is normal or not -occurrence of
certain diseases correlated with age eg; primary herpetic
gingivostomatitis(6months to 6years) nursing caries
sex-girls mature earlier than boys-require treatment earlier -some
diseases shows sex predilection eg: anorexia-females hemophilia -
males
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 race/ethnic origin:-certain religious cultures depends
the etiology of certain diseases.
 Address-
communication -to chart out appointments for patients
from distant places -to know endemic status of disease in
the locality
 Socio economic status-
to know about the nourishment, hygiene, payment
capacity of the patient
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CHIEF COMPLAINT
An examination should always be initiated by
obtaining the patient’s chief complaint. This is
critical, as it will provide information as to what
symptoms or pathology our subsequent tests will be
searching for. It is usually documented in the patients
words, or in case of a young minor, the parent’s or
guardian’s words. This should be duly signed by the
patient as well as initialed by the clinician as
verification . Non odontogenic pains sometimes
have a critical role of chief complaing during making
a diagnosis.
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PRESENT DENTAL HISTORY
Understanding previous dental history is a critical step
when obtaining information related to the chief
complaint. It is important to determine whether a
patient has had any recent dental treatment in the area
where he or she is experiencing discomfort.
 History of trauma
 Previous dental treatment
 Character of pain, loaction, duration, medications.
 Discomfort , and what it triggers
 Pain intensity level, help in determining the choice of
analgesic.
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 Localization: “Can you point to the offending tooth?” In addition, localization
allows subsequent diagnostic tests to focus more on this particular tooth.
When the symptoms are not well localized, the diagnosis is a greater
challenge.

Commencement: “When did the symptoms first occur?” A patient who is
having symptoms may remember when these symptoms started. Sometimes,
the patient will even remember the initiating event: It may be spontaneous in
nature, it may have begun after a dental visit for a restoration, trauma may be
the etiology, or biting on a hard object may have initially produced the
symptoms. However, the clinician should resist the tendency to make a
premature diagnosis based on these circumstances

Intensity: “How intense is the pain?” It often helps to quantify how much pain
the patient is actually having. The clinician might ask, “On a scale from 1 to 10,
with 10 the most severe, how would you rate your symptoms?” Hypothetically,
a patient could present with “an uncomfortable sensitivity to cold” or “an
annoying pain when chewing” but might rate this “pain” only as a 2 or a 3.
These symptoms certainly contrast with the type of symptoms that prevent a
patient from sleeping at night.
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 Localization: “Can you point to the offending tooth?” In addition, localization
allows subsequent diagnostic tests to focus more on this particular tooth.
When the symptoms are not well localized, the diagnosis is a greater
challenge.

Commencement: “When did the symptoms first occur?” A patient who is
having symptoms may remember when these symptoms started. Sometimes,
the patient will even remember the initiating event: It may be spontaneous in
nature, it may have begun after a dental visit for a restoration, trauma may be
the etiology, or biting on a hard object may have initially produced the
symptoms. However, the clinician should resist the tendency to make a
premature diagnosis based on these circumstances

Intensity: “How intense is the pain?” It often helps to quantify how much pain
the patient is actually having. The clinician might ask, “On a scale from 1 to 10,
with 10 the most severe, how would you rate your symptoms?” Hypothetically,
a patient could present with “an uncomfortable sensitivity to cold” or “an
annoying pain when chewing” but might rate this “pain” only as a 2 or a 3.
These symptoms certainly contrast with the type of symptoms that prevent a
patient from sleeping at night.
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 Provocation and Relief of Pain: “What produces or
reduces the symptoms?” Mastication and locally applied
temperature changes account for the majority of initiating
factors that cause dental pain. The patient may relate that
drinking something cold causes the pain or possibly that
chewing or biting is the only stimulus that “makes it hurt.” The
patient might say that the pain is only reproduced on “release
from biting

Duration: “Do the symptoms subside shortly, or do they linger after
they are provoked?” The difference between a cold sensitivity that
subsides in seconds and one that subsides in minutes may determine
whether a clinician repairs a defective restoration or provides
endodontic treatment
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Patients need to share their medical problems with
clinicians so that the data can be used in planning
treatment. Health history is one of the most important
steps in diagnosis and treatment planning.
• Illness
• History of bleeding
• Medications
Patients of african american heritage should be checked
for sickle cell anemia, chronic use of aspirin , patients on
pills or drugs. During these interviews, the clinician-
patient relationship tends to crystallize.
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CLINICAL EXAMINATION
In general the clinical examination should follow a logical sequence,
from general to specific, from the more obvious to less obvious, from
the external to the internal.
• BLOOD PREESURE – 120/80 for less than 60 yrs age .
130/90 for greater than 60 yrs age.
• PULSE RATE- 60/100 beats per minute.
• RESPIRATORY RATE- 16/18 BREATHS PER MINUTE.
• TEMPREATURE - 98.6*F [ 37*c ]
• CANCER screening should be done by palpation of lymph nodes, white
spots, bumps, non healing sore, numbness or constant pain, repeated
bleeding in mouth without cause.
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Signs of physical limitations,
facial asymmetry visual and
palpation of neck and face
regions are required.
• Cervical and submandibular
lymph nodes inspection.
• Loss of defination on nasolabial
fold of one side of the nose may
be a sight for canine space
infection.
• Swelling associated with upper
lip may be a criteria for maxillary
anterior teeth infection.
• Buccal space infection are
associated with mostly
premolars and 1st molars.
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Intraoral swellings
should be palpated and
searched for whether
ther are:-
• Diffuse or localize
• Firm or fluctuant
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INTRAORAL SINUS TRACTS
 On occasion a chronic endodontic infection will drain through an
intraoral communication to the gingival surface and is known as
a sinus tract. This pathway, which issometimes lined with
epithelium, extends directly from the source of the infection to a
surface opening, or stoma, on the attached gingival surface. The
term fistula is often inappropriately used to describe thistype of
drainage. The fistula, by definition, is actually an abnormal
communication betweentwo internal organs or a pathway between two
epithelium-lined surfaces.
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In general, a periapical infection that has an
associated sinus tract is not painful, although often
there is a history of varying magnitude before the sinus
tract development. Besides providing a conduit for the
release of infectious exudate and the subsequent relief
of pain, the sinus tract can also provide a useful aid in
determining the source of a given infection.The stoma
of the sinus tract may be located directly adjacent to or
at a distant site from the infection. To trace the sinus
tract, gutta-percha cone is threaded into the opening
of the sinus tract. Although this may be slightly
uncomfortable to the patient, the cone should be
inserted until resistance is felt. This will direct the
clinician to which tooth is involved, and more
specifically, which root of that tooth is the source of the
pathosis.
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If the opening is in the gingival crevice, it is normally
present as a narrow defect in one or two isolated areas
along the root surface. When a narrow defect is present,
the differential diagnosis must include the opening of a
periradicular endodontic lesion, a vertical root fracture,
or the presence of a developmental groove on the root
surface. This type of sinus tract can be differentiated
from a primary periodontal lesion because the latter
generally presents as a pocket with a broad coronal
opening and more generalized alveolar bone loss around
the root.
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PALPATION
In the course of the soft tissue examination, the alveolar
hard tissues should also be palpated. Emphasis should
be placed on detecting any soft tissue swelling or bony
expansion, especially noting how it compares with and
relates to the adjacent and contralateral tissues. In
addition to objective findings, the clinician should
question the patient about any areas that feel unusually
sensitive during this palpation part of the examination.
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PERCUSSION
Pain to percussion does not
indicate that the tooth is vital
or nonvital, but is rather an
indication of inflammation in
the periodontal ligament
(i.e., symptomatic apical
periodontitis). This
inflammation may be
secondary to physical trauma,
occlusal prematurities,
periodontal disease, or the
extension of pulpal disease
into the periodontal ligament
space.
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Before percussing any teeth, the clinician should tell
the patient what will transpire The contralateral tooth
should first be tested as a control, as well as several
adjacent teeth that are certain to respond normally. The
testing should initially be done gently, with light
Pressure being applied digitally with a gloved finger-
tapping. If the patient cannot detect any significant
difference between any of the teeth, the test should be
Repeated using the blunt end of an instrument, like the
back end of a mirror handle. The teeth should first be
Percussed occlusally, and if the patient discerns no
difference, the test should be repeated, percussing the
buccal and lingual aspects of the teeth.
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MOBILITY
Like percussion testing, an increase
in tooth mobility is not an
indication of pulp vitality. It is merely
an indication of a compromised
periodontal attachment apparatus.
This compromise could be the result
of acute or chronic physical trauma,
occlusal trauma, parafunctional
habits, periodontal disease, root
fractures, rapid orthodontic
movement, or the extension of
pulpal disease, specifically an
infection, into the periodontal
ligament space. Often the mobility
reverses to normal after the
initiating factors are repaired or
eliminated.
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Recording Tooth Mobility
+1 mobility: The first distinguishable sign of
movement greater than normal
+2 mobility: Horizontal tooth movement no greater
than 1 mm
+3 mobility: Horizontal tooth movement greater
than 1 mm, with or without the visualization of
rotation or vertical depressability
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PERIODONTAL EXAMINATIONS
Periodontal probing is an important part of any
Intraoral diagnosis. The measurement of periodontal
Pocket depth is an indication of the depth of the gingival
sulcus, which corresponds to the distance between the
height of the free gingival margin and the height of the
attachment apparatus below. Using a calibrated
periodontal probe, the clinician should record the
periodontal pocket depths on the mesial, middle, and
distal aspects of both the buccal and lingual sides of the
tooth, noting the depths in millimeters. The periodontal
probe is “stepped” around the long axis of the tooth,
progressing in 1-mm increments.
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Recording Furcation Defects
Class I furcation defect: The furcation can be probed
but not to a significant depth.
Class II furcation defect: The furcation can be entered
into but cannot be probed completely through to the
opposite side.
Class III furcation defect: The furcation can be
probed completely through to the opposite side.
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NEUROPHYSIOLOGY OF PULP AND PAIN TRANSMISSION
 In the pulp chamber coronal nerve bundles diverge and branch out
towards the pulpo-dentine border .
 Nerve divergence continues until each bundle looses its integrity and
smaller fibre groups travel towards the dentine.
 This route is relatively straight until the nerve fibres form a loop
resulting in a mesh that is termed the plexus of Rashkow.
 The density of this nerve plexus is well developed in the peripheral
pulp along the lateral wall of coronal and cervical dentine and along
the occlusal wall of the pulp chamber.
 The nerve fibres emerge from their myelin sheaths and branch
repeatedly to form the subodontoblastic plexus.
 Finally, the terminal axons exit from their Schwann cell investiture and
pass between the odontoblasts as free nerve endings
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 Two types of sensory fibres are present in the pulp,the myelinated (A fibres) and
unmyelinated C fibres.
 The A fibres predominantly innervate the dentine and are grouped according to
their diameter and conduction velocities into Ab and Ad fibres.
 The Ab fibres maybe more sensitive to stimulation than the Ad fibres, but
functionally these fibres are grouped together. Approximately90% of A fibres are Ad
fibres.
 The C fibres innervate the body of the pulp.
 The Ad fibres have lower electrical thresholds than the C fibres and respond to a
number of stimuli which do not activate C fibres (Olgart 1974).
 Ad fibres mediate acute, sharp pain and are excited by hydromechanical events in
dentinal tubules such as drilling or air-drying (Byers1984).
 Ad fibres may act as mechanoreceptors that trigger withdrawal reflexes so that
potentially damaging forces may be avoided (Dong et al. 1985, Olgart et al. 1988,
Byers & Na¨rhi 1999).
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 Once activated, the pain initiated by C fibres can radiate in the face
and jaws. C fibre pain is associated with tissue injury and is modulated
by inflammatory mediators, vascular changes in blood volume and
flow,and increases in pressure (Na¨rhi 1990).
 The response to a given stimulus will be greatest where neural density
is the highest. Key factors in pulp testing are the thickness of the
enamel and dentine and the number of nerve fibres in the underlying
pulp.
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PULPAL DIAGNOSIS
INGLE 1st edition
PULPALGIA is
acute and chronic
pulpalgia
Newer terminologies
reversible and
irreversible pulpitis
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PULPAL DIAGNOSIS
DIAGNOSTIC TERMINOLOGY AS RECOMMENDED BY AMERICAN
BOARD OF ENDODONTIST , 2007
PULPAL:-
• Normal pulp
• Reversible pulpitis
• Irreversible pulpitis
additional descriptions:-
symptomatic
asymptomatic
hyperplastic pulpitis { pulp polyp}
internal resorption
• Pulp necrosis
• Previously treated
• Previously initiated therapy
additional pulpal terms:-
calcific metamorphosis
dystrophic metamormhosis
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APICAL { PERIAPICAL}:-
• Normal apical tissues
• Symptomatic apical periodontitis{ acute}
• Asymptomatic apical periodontitis{ chronic}
lateral of furcal
• Acute apical abscess
• Chronic apical abscess{ suppurative apical abscess}
lateral or furcal
additional periradicular terms:-
apical scar
cellulitis
condensing osteitis
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
A complete endodontic diagnosis is made up of two parts:
1. Pulpal diagnosis
2. Periapical diagnosis
PULPAL DIAGNOSIS
Normal pulp – A clinical diagnostic category in which the pulp is symptom free and
normally responsive to vitality testing.
Reversible pulpitis – A clinical diagnosis based upon subjective and objective findings
indicating that the inflammation should resolve and the pulp return to normal.
Irreversible pulpitis – A clinical diagnosis based on subjective and objective findings
indicating that the vital inflamed pulp is incapable of healing.
Additional descriptions:
Symptomatic – Lingering thermal pain, spontaneous pain, referred pain
Asymptomatic – No clinical symptoms but inflammation produced by caries,
caries excavation, trauma, etc.
Pulp necrosis – A clinical diagnostic category indicating death of the dental pulp. The
pulp is non-responsive to vitality testing.
Previously Treated – A clinical diagnostic category indicating that the tooth has been
endodontically treated and the canals are obturated with various filling materials, other
that intracanal medicaments.
Previously Initiated Therapy – A clinical diagnostic category indicating that the tooth
has been previously treated by partial endodontic therapy (e.g. pulpotomy, pulpectomy).
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 PERIAPICAL DIAGNOSIS
Normal apical tissues – Teeth with normal periradicular tissues that will not be
abnormally sensitive to percussion or palpation testing. The lamina dura surrounding the
root is intact and the periodontal ligament space is uniform.
Symptomatic apical periodontitis – Inflammation, usually of the apical
periodontium, producing clinical symptoms including painful response to biting and
percussion. It may or may not be associated with an apical radiolucent area. (This
category includes what many of us call Acute Apical Periodontitis & Phoenix Abscess)
Asymptomatic apical periodontitis – Inflammation and destruction of apical
periodontium that is of pulpal origin, appears as an apical radiolucent area and does not
produce clinical symptoms. (This is what many of us have previously called a Chronic
Apical Periodontitis)
Acute apical abscess – An inflammatory reaction to pulpal infection and necrosis
characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus
formation and swelling of associated tissues.
Chronic apical abscess – An inflammatory reaction to pulpal infection and necrosis
characterized by gradual onset, little or no discomfort and the intermittent discharge of
pus through an associated sinus tract.
NEWER AMERICAN BOARD OF ENDODONTIST RECOMMENDED DIAGNOSTIC
TRMINOLOGY, 2011, STILL UNDER DISCUSSION
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DENTAL PULP TESTING
Dental pulp testing is a useful and essential
diagnostic aid in endodontics. Pulp sensibility tests
include thermal and electric tests, which
extrapolate pulp health from sensory response.
Whilst pulp sensibility tests are the most
commonly used in clinical practice, they are not
without limitations and shortcomings. Pulp vitality
tests attempt to examine the presence of pulp
blood flow, asthis is viewed as a better measure of
true health than sensibility. Laser Doppler
flowmetry and pulse oximetry are examples of
vitality tests.
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Whilst the prospect is promising, there are still
many practical issues that need to be addressed
before vitality tests can replace sensibility tests as
the standard clinical pulp diagnostic test. With all
pulp tests, the results need to be carefully interpreted
and closely scrutinised as false results can lead to
misdiagnosis which can then lead to incorrect,
inappropriate, or unnecessary treatment.
DENTAL PULP TESTING : A REVIEW International
Journal of Dentistry vol 2009,
45

Diagnostic Objectives of Pulp Testing
Assessment of Pulp Health Based on Its Qualitative
 Sensory Response. The assessment of pulp health based on its
qualitative sensory response is commonly done:
(i) prior to restorative, endodontic, and orthodontic procedures
(ii) as a follow-up and for monitoring the pulp after trauma to
the teeth,
(iii) in differential diagnoses, such as excluding periapical
pathosis of pulp origin.
A. H. Rowe and T. R. Pitt Ford, “The assessment of pulpal
vitality,” International Endodontic Journal, vol. 23, no. 2, pp.
77–83, 1990.
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Pulp Vitality Testing, Pulp Sensibility Testing,
and Pulp Sensitivity
Pulp Vitality Testing: Assessment of the Pulp’s Blood
Supply.
Pulp Sensibility Testing: Assessment of the Pulp’s Sensory
Response.
Pulp Sensitivity: Condition of the Pulp Being Very
Responsive to a Stimulus.
 S. N. Bhaskar and H.M. Rappaport, “Dental vitality tests
andpulp status,” The Journal of the American Dental
Association,vol. 86, no. 2, pp. 409–411, 1973.
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Replication of Symptoms and Triggers for Pain
DiagnosticPurposes. The replication of symptoms
and triggers for pain diagnostic purposes [2, 13] is
commonly done:
(i) to localise the source of pain,
(ii) as an aid in excluding nonodontogenic orofacial
pain.
J. I. Ingle, “Diagnostic acuity versus negligence,”
Journal ofEndodontics, vol. 28, no. 12, pp. 840–841,
2002.
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Pulp Nociception Mechanism.
Brannstrom’s hydrodynamic theory proposed that
pulp pain is a result of nociceptors activated by
fluid movement with possible other irritants
through the patent dentine tubules . The fast
conducting myelinated Aδ-fibres are known to be
responsible for the acute “sharp shooting pain”
whereas the slower conducting unmyelinated
C-fibres are attributed to the “burning” pain with
slower onset.
M. Brannstrom, “The hydrodynamics of the dental tubuleand
pulp fluid: its significance in relation to dentinal sensitivity,” in
Proceedings of the Annual Meeting of the American Institute of
Oral Biology, vol. 23, p. 219, 1966.
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PULP TESTING TECHNIQUES AND EFFECTIVENESS
PULP SENSIBILITY TEST:-
1. Thermal test :-
The application of agents to the teeth to increase or decrease
temperature and to stimulate pulp sensory responses through thermal
conduction comes under thermal tests.
COLD TEST:-
Cold is the primary pulp testing method for many clinicians
today. To be most reliable, cold testing should be used in conjunction with
an electric pulp tester so that the results from one test will verify the
findings of the other test. Agents most frequently used for cold test are :-
ice , refrigant spray, carbon dioxide snow, most recent 1,1,1,2-
tetrafluoroethane.
If a mature, untraumatized tooth does not respond to both electric
pulp test and cold test, then the pulp should be considered
necrotic. However, a multirooted tooth, with at least one root containing
vital pulp tissue, may respond to a cold test even if one or more of the
roots contain necrotic pulp tissue. Cold testing can be accomplished, by
individually isolating teeth with a rubber dam.
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This technique for cold testing is especially useful for patients presenting
with porcelain jacket crowns or porcelain-fused-to-metal crowns where
there is no natural tooth surface (or much metal) accessible. Another
Benefit of this technique for cold testing is that it requires no
armamentarium except for a rubber dam. If a clinician chooses to perform
this test with sticks of ice, then the use of the rubber dam is
recommended because melting ice will run onto adjacent teeth and
gingiva, yielding potentially false-positive responses.
ICE:- This is perhaps the simplest cold testing agent requiring practically zero
cost to prepare and it can be made in a standard household freezer.
However the clinical handling, infection control issues, and the direct
application of ice can be difficult and problematic.
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Carbon dioxide snow (CO2), CO2 snow, or dry ice, is
prepared from a pressurized liquid CO2 cylinder using a
commercially available apparatus known as the Odontotest
(Fricar A.G. Zurich, Switzerland).
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REFRIGERANT SPRAY
 The most popular method of
performing cold testing is
with a refrigerant spray. It is
readily available, easy to use,
and provides test results that
are reproducible, reliable,
and equivalent to that of
CO2.One of the current
product contains 1,1,1,2-
tetrafluoroethane, which has
zero ozone depletion
potential and is
environmentally safe. It has a
temperature of −26.2° C.
53

Rate of Temperature Decrease and Speed of Pulp
Response.
 Recorded in vitro temperatures for DDM (−50◦C), EndoFrost (−50◦C), and TFE
(−26◦C) are all higher than CO2(−78◦C) . However, CO2 is not as cold when used
clinically, where it has been reported to be −56◦C, similar to DDM which is known
to have a temperature as low as −50◦C . The in vivo temperature for EndoFrostTM is
approximately −28◦C whilst TFE is −18.5◦C. Some in vitro studies have shown that
CO2produces a slightly larger decrease in temperature in a short period of time,
especially with metallic restorations (such as amalgam and gold restorations) which
allow better thermal conduction.
V. R. Jones, E. M. Rivera, and R. E. Walton, “Comparison of carbon
dioxide versus refrigerant spray to determine pulpal responsiveness,”
Journal of Endodontics, vol. 28, no. 7, pp.531–533, 2002.
 When testing multiple teeth, such as the whole dental arch, CO2 is more
convenient as the rate of dissipation is much lower than that of any of the
other refrigerants.
S.O.Miller, J. D. Johnson, J. D. Allemang, and J. M. Strother,“Cold testing
through full-coverage restorations,” Journal ofEndodontics, vol. 30, no. 10,
pp. 695–700, 2004.
55

Safety Concerns of Cold Tests.
 Concerns have been raised in the past about the possible damaging
effects of cold testing agents with particular reference to CO2 given its
measured laboratory temperature of −78◦C. Ehrmann described the
phenomenon of Leidenfrost” “that occurs when a small amount of
CO2 snow enters the oral cavity but causes no harm in spite of its
physical contact with the oral mucosa. This is due to an insulating
layer of gaseous CO2 surrounding the melting mass as the dry ice “film
boils” so there is insufficient times for the tissue burns to occur.
E. H. Ehrmann, “Pulp testers and pulp testing with particular reference
to the use of dry ice,” Australian Dental Journal, vol.22, no. 4, pp. 272–279,
1977.
 Lutz et al. found that cracks may be formed on enamel surfaces from direct
CO2 snow contact.
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HEAT TEST
 Heat testing is most useful when a patient's chief complaint
is intense dental pain on contact with any hot liquid or food.
When a patient is unable to identify which tooth is sensitive, a
heat test is appropriate. Starting with the most posterior tooth
in that area of the mouth, each tooth is individually isolated
with a rubber dam.
 An irrigating syringe is filled with a liquid (most commonly
plain water) that has a temperature similar to that which would
cause the painful sensation. That tooth will exhibit an
immediate, intense painful response to the heat. With heat
testing a delayed response may occur, so waiting 10 seconds
between each heat test will allow sufficient time for any
onset of symptoms.
57

 That tooth will exhibit an immediate,
intense painful response to the heat.
With heat testing a delayed response
may occur, so waiting 10 seconds between
each heat test will allow sufficient time
for any onset of symptoms.
 If the heat test confirms the results of
other pulp testing procedures,
emergency care can then be provided.
Often a tooth that is sensitive to heat
may also be responsible for some
spontaneous pain. In these cases the
patient may present with cold liquids
in hand just to minimize the pain. In
these cases, the application of cold to a
specific tooth may eliminate the pain
and greatly assist in the diagnosis.
58

Safety Concerns of Heat Tests
 The temperature of melting gutta percha used in pulp
testing is approximately 78◦C but it has been reported
to be up to 150◦C . Zach et al.noted that an increase of 11◦C
that occurs during restorative procedures without
adequate cooling can harm the pulp. Therefore,
prolonged contact with heat is a safety concern.
 In the in vitro portion of the Fuss et al. study, it was
shown that heat testing using gutta percha in the
manner described above increased pulp temperature by
less than 2◦C with less than five seconds of
application—a temperature change that is unlikely to
have caused pulp damage.
59

ELECTRIC PULP TESTING
Electric pulp testing (EPT) has been available for more than a century
and used in dental practice worldwide. Electric pulp testing (EPT)
works on the premise that electrical stimuli cause an ionic change
across the neural membrane, thereby inducing an action potential with
a rapid hopping action at the nodes of Ranvier in myelinated nerves.
HISTORY:-
 Magitot in his book Treatise on Dental Caries 1867 (cited in Prinz1919). Magitot
advocated the use of an induction current.
 Roentgen in 1895 was probably the first to introduce the use of electricity
clinically for diagnosing diseases of the pulp (Grossman 1976).
 Mid-1950s bipolar instruments were used, while almost all testers in use today
are monopolar.
 Newer testers are based on negative polarity .
{Kitamura et al. 1983, Cooley et al. 1984,Dummer & Tanner 1986, Dummer
et al. 1986,Robinson 1987}
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TECHNIQUE:-
• Selection of diseased tooth and control
tooth.
• Proper isolation. { rubber dam }
• Conducting media selection.{ tooth paste}
Mickel AK, Lindquist KAD, Chogle S, Jones JJ, Curd F
(2006)Electric pulp tester conductance through various
interfacemedia. Journal of Endodontics 32, 1178–80.
• Completion of circuit
• Readings recorded .
AREAS TO BE SELECTED:-
Incisal edges of anterior teeth and facial
surfaces of posterior teeth. Electrode placement
on molars on the tip of the mesiobuccal
cusp.{Lin J, Chandler NP, Purton D, Monteith(2007)
Appropriate electrode placement site for electric pulp
testing first molar teeth. Journal of Endodontics 33, 1296–
8}. 61

LIMITATIONS
 Patients on pacemakers . But recent studies shows they don’t produce any
interfrence .{Wilson BL, Broberg C, Baumgartner JC, Harris C, Kron J(2006) Safety of electronic apex
locators and pulp testers inpatients with implanted cardiac pacemakers or cardioverter/defibrillators.
Journal of Endodontics 32, 847–52.}
 Patients with crowned teeth, with orthodontic bands( may be elevated
uptill 9 months{caveetal 2002}, frightful and uncooperative patients.
 Traumatized tooth. { concussed}
 Immature permanent teeth.{as full development of the plexus of Rashkow
does not occur until 5 years aftertooth eruption (Johnsen 1985)}
 RECENT APPLICATIONS IN ANALGESIA:-The EPT offers a useful means
for measurement of local anaesthesia.
Modaresi J, Dianat O, Mozayeni MA (2006) The efficacycomparison of ibuprofen, acetaminophen-codeine, and
placebopremedication therapy on the depth of anesthesiaduring treatment of inflamed teeth. Oral Surgery, OralMedicine,
Oral Pathology, Oral Radiology and Endodontics102, 399–403.
62

PULP VITALITY TESTING
To determine the vitality of the pulp the ideal test should be objective,
painless, reliable, reproducible, inexpensive. The most common and
other experimental tests are listed below.
They are divided into invasive and noninvasive types:-
Invasive:-
radioisotope clearence
H2 gas desaturation
Noninvasive:-
laser Doppler flowmetry
pulse oximetry
dual wavelength spectrophotometry
photoplethysmography
measurement of surface temperature
63

Pulse oximeter
 The oximeter applies a principle known as the Beer-Lambert
law, which states that an unknown concentration of solute
(hemoglobin) dissolved in known solvent(blood) can be
assessed by the light absorption of the solute.
 Measures only the arterial oxygen content{Gopikrishna V, Tinagupta K,
Kandaswamy D. Comparison of electrical, thermal, and pulse oximetry methods for assessing pulp vitality in
recently traumatized teeth. JEndod 2007;33:531–5.}
• A pulse oximeter uses a probe containing two light-emitting
diodes (LEDs): one transmits red light (approximately 660 nm),
and the other transmits infrared light (900–940 nm) to measure
the absorption of oxygenated and deoxygenated hemoglobin,
respectively (it operatesat 500 on/off cycles/s). Oxygenated and
deoxygenated hemoglobin absorb different amounts of red and
infrared light. This light is received by a photodetector diode
connected to a microprocessor.
64

DENTAL SENSOR SYSTEM BY
NOBLETT ET AL
65

INDICATIONS:-
• It is especially applicable to recently traumatized teeth.
• Pulse oximetry can be valuable to endodontists who want to use sedation
techniques or frequently treat medically compromised patients.
• It is also useful in monitoring patients under general anesthesia.
CONTRAINDICATIONS:-
 Intrinsic limitations include excessive carbon dioxide in the blood
stream interfering with deoxygenating values. Increased acidity
variables such as low peripheral perfusion, hemoglobin disorders,
vasoconstriction.
 Extrinsic interferences may be caused by the probe movement,
overhead Xenon arc lamps .This technique cannot be used for pulp
testing in extensively restored teeth ( with full coverage restorations).
Pulse Oximetry: Review of a Potential Aid
in Endodontic Diagnosis
Hamid Jafarzadeh, DDS, MSc,* and Paul A. Rosenberg, DDS† JOE VOL 35, MARCH 2009
66

Modified ear probe by
Goho
Custom made probe by
Gopikrishna et al
67

LASER DOPLER FLOWMETRY
 Laser Doppler flowmetry (LDF) is a method used to assess blood
flow in microvascular systems.
 Attempts are being made to adapt this technology to assess
pulpal blood flow.
 A diode is used to project an infrared light beam through the
crown and pulp chamber of a tooth. The infrared light beam is
scattered as it passes through the pulp tissue.
 The Doppler principle states that the light beam will be
frequency-shifted by moving red blood cells but will remain
unshifted as it passes through static tissue. The average Doppler
frequency shift will measure the velocity at which the red blood
cells are moving.[
68

TOOTH TEMPREATURE MEASUREMENT
Tempreature measurements as a diagnostic procedure
has been described by use of:-
 Thermocouples
 Infrared thermometers
 Miniature thermometers
 Thermistors
 Infrared thermography
 Cholesteric liquid crystals
70

Precautions should be taken to ask the patient to refrain from smoking,
and eating or drinking 60 minutes before the procedure. The room should
be insulated and draft free, and the tempreature should be maintained at
20* c .
Use of rubber dam is advocated
Infrared thermography imaging ex:- hughes probeye thermal video syatem
can detect tempreature changes as small as 0.1*c.
Tempreature changes from gingival margin to incisal edges decrease by
approximately 2.5*c.
71

CHOLESTERIC LIQUID CRYSTALS
“MESOPHASE” a state of ester in
which neither liquid nor crystal state
exist.
These crystals produces different
colors at different mesophaes that
could then be caliberated according to
the temp that produces the colors.
Major advantage is simplicity of use
72

BITE TEST
• The tooth may be sensitive to biting when
the pulpal pathosis has extended into the
periodontal ligament space, creating a
periradicular periodontitis, or the sensitivity may
be present secondary to a crack in the tooth.
• For the bite test to be meaningful a device
should be used that will allow the clinician to
apply pressure to individual cusps or areas of the
tooth.
• A variety of devices have been used for bite
tests, including cotton applicators, toothpicks,
orangewood sticks, and rubber polishing wheels.
• The Tooth Slooth (Professional Results,
Laguna Niguel, CA) and FracFinder (Hu-Friedy,
Oakbrook, IL) are just two of the commercially
available devices used for the bite test.
73

TEST CAVITY PREPRATION
 This method is used only when all other test methods are deemed
impossible or the results of the other tests are inconclusive.
 An example of a situation in which this method might be used is when
the tooth suspected of having pulpal disease has a full coverage crown.
 This is accomplished with a high-speed #1 or #2 round bur with proper
air and water coolant. The patient is not anesthetized while this
procedure is performed, and the patient is asked to respond if any
painful sensation is felt during the drilling procedure.
 If the patient feels pain once the bur contacts sound dentin, the
procedure is terminated.
74

SELECTIVE ANESTHESIA
 Sometimes the patient may not even be able to specify whether the
symptoms are emanating from the maxillary or mandibular arch. In
these instances, when pulp testing is inconclusive, selective anesthesia
may be helpful.
 First selectively anesthetize the maxillary arch. This should be
accomplished by using a periodontal ligament (intraligamentary)
injection. The injection is administered to the most posterior tooth in
the quadrant of the arch that may be suspected, starting from the distal
sulcus.
 The anesthesia is subsequently administered in an anterior direction,
one tooth at a time, until the pain is eliminated. If, after an appropriate
period of time, the pain is not eliminated, the clinician should similarly
repeat this technique on the mandibular teeth below.
 It should be understood that periodontal ligament injections may
inadvertently anesthetize an adjacent tooth, and thus are more useful
for identifying the arch rather than the specific tooth.
75

 WILLIAM KONRAD ROENTGEN, 1895.
 Dr Otto Waloff took the first radiograph in his
mouth
 Dr Weston . Price bisecting angle technique.
 Dr. C. Edmund Kells paralleling angle
technique.
77

• Aid in diagnosis of hard tissue and periradicular
structures.
• Determine the number, location, shape, size, direction
of root canals.
• Estimate and confirm the length of the canals
• Aid in locating a pulp space markedly calcified
• Confirm the position and adaptation of master cone.
• Aid in evaluation of master cone.
• Help to find and confirm apex during root end
surgery.
• Evaluate in follow up films, the outcome of treatment
78

 The primary radiograph used in endodontics is the periapical
radiograph.
 In diagnosis this film is used to identify abnormal conditions in the
pulp and periradicular tissues. It is also used to determine the
number of roots and canals, location of canals, and root curvatures.
 Because the radiograph is a two-dimensional image (a major
limitation), it is often advantageous to expose additional
radiographs at different horizontal or vertical angulations when
treating multicanal and multirooted teeth.
 A radiograph should depict the tooth in the center of the films.
 In addition, at least 3 mm of bone must be visible beyond the apex
of the tooth. Failure to capture this bony area may result in
misdiagnosis, improper interpretation of the apical extent of a root,
or incorrect determination of file lengths for canal cleaning and
shaping
79

 The bite-wing radiograph may be
useful as a supplemental film.
 This information includes the
anatomic extent of the pulp chamber,
the existence of pulp stones or
calcifications, recurrent caries, the
depth of existing restorations, and any
evidence of previous pulp therapy.
 The bite-wing also indicates the
relationship of remaining tooth
structure relative to the crestal height
of bone. Thus it can aid in
determining the restorability of the
tooth.
80

 Radiographic changes from bone loss will not be detected if
the bone loss is only in cancellous bone. However,
radiographic evidence of pathosis will be observed once this
bone loss extends to the junction of the cortical and
cancellous bone, as was illustrated by Bender and Seltzer.
By comparison, the distal roots of mandibular first molars
and both roots of mandibular second molars are generally
positioned more centrally within the cancellous bone, as are
maxillary molars, especially the palatal roots. Periapical
lesions from these roots must expand more before they
reach the cortical–cancellous bone junction and are
recognized as radiographic pathosis.
81

 For endodontic purposes, the paralleling technique produces the most
accurate periradicular radiograph.
 long-cone or right-angle technique.
 The film is placed parallel to the long axis of the teeth, and the central
beam is directed at right angles to the film and aligned through the root
apex
 film is placed away from the tooth, toward the middle of the oral cavity.
 The long-cone (i.e., 16 to 20 in) aiming device is used in the paralleling
technique to increase the focal spot-to-object distance]
 paralleling technique reduces the possibility of superimposing the
zygomatic processes over the apices of maxillary molars.
 If properly used, the paralleling technique will provide the clinician with
films with the least distortion, minimal superimposition, and utmost
clarity. 82

 Variations in size and shape of the oral structures (e.g.,
shallow palatal vault, tori, or extremely long roots) or
gagging by the patient can make true parallel placement of
the film impossible.
 To compensate for difficult placement, the film can be
positioned so that it diverges as much as 20 degrees from the
long axis of the tooth, with minimal longitudinal distortion.
 Although this orientation introduces a small degree of
foreshortening, it increases periradicular definition in this
troublesome maxillary posterior region. The Snapex system
(DENTSPLY Rinn, Elgin, IL), a film holder and aiming
device originally designed for the bisecting-angle technique,
has been altered for the modified paralleling technique.[19
83

 The bisecting-angle technique is not preferred for endodontic
radiography
 The basis of this technique is to place the film directly against the
teeth without deforming the film.
 Thus, by directing the central beam perpendicular to an imaginary
line that bisects the angle between tooth and film, the length of the
tooth's image on the film should be the same as the actual length
of the tooth.
 Although the projected length of the tooth is correct, the image
will show distortion because the film and object are not parallel
and the x-ray beam is not directed at right angles to both.
 The technique produces additional error potential, because the
clinician must imagine the line bisecting the angle (an angle that,
in itself, is difficult to assess
84

XCP ( EXTENSION CONE
PARALLELING SYSTEM) ENDO RAY 2
88

SNAP A RAY FILM
HOLDER
SNAPEX FILM HOLDER
AND AIMING RING
89

 Mostly classified on
the basis of speed .
 Most commonly used
is E speed film .
 Latest is F speed film.
90

 Walton introduced an refinement in dental
radiography by demonstrating a simple
technique through which the third dimension
can be easily visualized.
 The basic technique was the to vary the
horizontal angulation upto 20*.
 This was introduced as clark rule, SLOB rule
 Ingle stated it as MBD{ always shoot from
mesial and the buccal root will be distal.}
91

 Maxillary anterior teeth{ straight facial}
 Maxillary PM and Molars{ mesial angle}
 Mandibular incisor teeth{ diatal angle}
 Mandibular canine{ mesial angle}
 Mandibular PM{mesial}
 Mandibular molars{ distal}
92

 Diagnostic quality of conventional radiography has been the
advent of digital radiography.. Digital radiography has the ability to
capture, view, magnify, enhance, and store radiographic images in
an easily reproducible format that does not degrade over time.
 Digital radiography uses no x-ray film and requires no chemical
processing. Instead, a sensor is used to capture the image created
by the radiation source. This sensor is either directly or remotely
attached to a local computer, which interprets this signal and,
using specialized software, translates the signal into a two-
dimensional digital image that can be displayed and enhanced.
The image is stored in the patient's file, typically in a dedicated
network server, and can be recalled as needed.
96

 Conventional images can be considered as
analog.
 Digital images are numeric and discrete in two
ways:- in terms of spatial distribution of
picture elements( pixels), and in terms of
different shades of gray of each pixel.
 A digital image consist of large collection of
pixels oraganized in a matrix of rows and
columns .
 Production of a digital image requires a process
of analog to digital.
97

 Until recently, x-ray film has had a
slightly better resolution than most
digital radiography images, at about
16 line pairs per millimeter (lp/mm).
 However, some sensor
manufacturers are now claiming to
have resolutions beyond that of film
and up to 22 lp/mm
 Under the best of circumstances, the
human eye can see only about 10
lp/mm.
 The digital sensors are much more
sensitive to radiation than
conventional x-ray film and thus
require 50% to 90% less radiation in
order to acquire an image.
98

 CHARGE COUPLE
DEVICES( CCD)
First direct digital image
receptor to be adapted for
intraoral imaging in 1987.
Uses a thin wafer of silicon
for image recording.
The silicon crystals when
exposed to radiation
produces element pixel
matrix producing electron
hole pairs.
Eg:- GENDEX, KODAK
SENSORS.
 COMPLEMENTARY
METAL OXIDE
SEMICONDUCTORE(
CMOS)
They are fundamentally
different from ccd in the
fact that that pixel charges
are read here.
Each pixel is isolated from its
neighboring pixels and is
directly connected to a
transistor.
Eg:- SHICK CMOS SENSOR
99

 Digitization of ionizing radiation first became a
reality in the late 1980s with the development of
the original RadioVisioGraphy (RVG) system by
Dr. Francis Mouyen. This system later was
marketed as the RVGui (Kodak Dental
Systems/Carestream Health
 Direct digital systems have three components: (1)
the “radio” component, (2) the “visio” component,
and (3) the “graphy” component.
100

 The “radio” component consists of a high-resolution sensor with an active
area that is similar in size to conventional film.
 However, length, width, and thickness vary slightly depending on the
respective system.
 The sensor is protected from x-ray degradation by a fiberoptic shield, and
it can be disinfected
 Wireless CDR sensors have become available through Schick
Technologies. This technology provides cable-free sensors to allow
enhanced mobility at chairside
 Sensors instantly transmit images directly from the mouth. The image is
automatically transmitted to the computer via radio waves. Images do
not need to be processed as with traditional film and storage phosphor
plates
101

 Consists of a video monitor
and display-processing
unit
 Manipulation of the image
is possible; this includes
enhancement, contrast
stretching, and reversing. A
zoom feature is also
available to enlarge a
portion of the image up to
full-screen size.
104

 The third component of a direct digital system is
the “graphy,” a high-resolution video printer that
provides a hard copy of the screen image, using
the same video signal.
 Indirect digital imaging or cordless systems, such
as Digora (Soredex-Finndent, Conroe, Texas) and
the DenOptix digital imaging system (Gendex, Des
Plaines, IL), involve the use of a reusable filmlike
plate without wires. The image to be scanned by a
laser (to digitize it before viewing on the
computer) is recorded on this plate.
105

 Orascopy and related endoscopic instruments, have been adapted for
enhanced visualization in endodontics and consist of either flexible or
rigid fiberoptic endoscopes.
 These fiberoptic probes are available in various diameters; the probes
provide a large depth of field, and refocusing is not needed after the
initial focus.
 Once the probe is applied, the clinician views the conventional or
surgical site from the magnified image displayed on the monitor.
 Endoscopic endodontics allows the clinician to have a nonfixed field of
vision, and probes can be manipulated at various angles and distances
from an object without loss of focus or image clarity.
 With orascopy, finite fracture lines, accessory canals, missed canals and
isthmuses, and apical tissues can be viewed.
106

 cone beam volumetric tomography (CBVT), also known as cone
beam computed tomography (CBCT) for diagnostic evaluation of
endodontically compromised teeth is now becoming very
popular with clinicians performing endodontic procedures
 Two-dimensional (2D) grayscale images, whether they are
conventional film or digital images, cannot accurately depict the
full three-dimensional (3D) representation of the teeth and
supporting structures
 CBVT allows the clinician to view the tooth and pulpal structures
in thin slices in all three anatomic planes: axial, sagittal, and
coronal.
 Several tools available in CBVT, such as changing the vertical or
horizontal angulation of the image “on the fly” or in real time, as
well as thin-slice, grayscale data of 0.1 mm thickness, will never
be available for conventional or even digital radiographic
assessment.
110

Three important parameters of cone-beam
imaging are described in the following
sections:
1. Voxel size
2. Field of view (FOV)
3. Slice thickness/measurement accuracy
111

THE IMAGING
SCIENCES I-CAT
 Cone-beam scanning machines
acquire their x-ray information
using low kV and low mA
exposure parameters in a single
pass from 180 to 360 degrees of
rotation.
 Besides lower exposure factors,
the image data in cone-beam
imaging is reconstructed from
isometric voxels; that is, the
images are constructed from
pixels that are cubic and have the
same dimensions for length,
width, and depth. These voxel
sizes are as small as 0.1 to 0.6 mm.[
112

A PIXEL (PICTURE ELEMENT), THE
IMAGE CAPTURE AND DISPLAY
ELEMENT OF ANY TRADITIONAL
DIGITAL IMAGE DISPLAYED ON THE
COMPUTER. SHADES OF GRAY OR
COLOR WILL BE DISPLAYED IN THESE
PIXELS TO REPRESENT A 2D IMAGE
A VOXEL (VOLUME ELEMENT). VOXELS
ARE ISOMETRIC PIXELS HAVING THE
SAME DIMENSION OR LENGTH ON ALL
SIDES. THEY ARE VERY SMALL (FROM 0.10
TO 0.60 MICRONS) AND ARE THE CAPTURE
ELEMENT FOR CONE BEAM IMAGING
DEVICES.
113

 The FOV ranges from as small as a portion of a dental arch to an area
as large as the entire head.
 Currently, the smallest FOV available is 37 × 50 mm , which may be
appropriate for a making them very suitable for endodontic
procedures.
 The selection of the FOV depends on several factors. Among the
most important are:
 1. Diagnostic task
2. Type of patient
3. Spatial resolution requirements
4. Clinician's confidence interpreting the acquired data volume
114

SPATIAL RESOLUTION
 All endodontic imaging
procedures require high
spatial resolution.
 Assessment of canal
structure, canal length, and
lesions of endodontic origin
(LEOs) exhibiting apical
change are all important
tasks requiring minute
detail.
 If CBVT is employed, the
data acquisition should be
performed at the smallest
voxel size. The smaller the
voxel size, the higher the
spatial resolution.
116

 Imaging Tasks Improved or Simplified by Cone
Beam Volumetric Tomography
 For endodontic treatment and assessments, there
are at least five primary imaging tasks whereby
CBVT scans have a distinct advantage over
traditional 2D radiographs. These include
evaluation of the following:
 1. Apical morphology and suspected lesions of
endodontic origin
2. Root canal system morphology
3. Presurgical visualization
4. Suspected root fractures and trauma
5. Internal and external root resorption
117

 Ultrasound real time imaging, also called real
time echotomography or echography, has been
widely used diagnostic technique in many
fields of medicine since 1942.
 Based on piezoelectric effect.
 Help to differentiate between a granuloma and
a cyst.
 Nowdayz the ultrasound imaging is
supplemented by colour power doppler ( CPD)
ultrasound .
124

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