DIAGNOSIS IN ENDODONTICS

1. DIAGNOSIS IN
ENDODONTICS

2. INTRODUCTION
Diagnosis is the process of identifying a
disease by careful investigation of its
symptoms and history.
An accurate diagnosis is the result of
synthesis of scientific knowledge, clinical
experience, intuition and common sense. The
process is thus both an art and science.

3. ENDODONTIC TRIAD
• HISTORICAL • CONTEMPORARY
DEBRIDEMENT
STERILIZATION APICAL SEAL
SUCCESS
DIAGNOSIS
ANATOMY &
DEBRIDEMENT
3D OBTURATION
SUCCESS

4. The four components of diagnostic
procedure are
1.Assemble all available facts
 Chief complaint
 Medical & Dental history Subjective symptoms
 History of the present condition
2. Screen & interpret the assembled clues and discover which
are genuine to the case
3. Differential Diagnosis
4. Operational or working diagnosis which is the final
diagnosis

5. PATIENT QUESTIONNARE
First Name:______________ Last Name:_______________
1. Are you experiencing any pain at this time? Yes ___ No ___
2. If yes, can you locate the pain? Yes ___ No ___
3. When did you first notice the symptoms? ________________________
4. Did symptoms occur suddenly or gradually? _____________________
5. Do you grind or clench your teeth? Yes ___ No ___
6. If so, do you wear a night guard? Yes ___ No ___
7. Has a restoration (filling 0r crown) been placed on this
tooth recently? Yes ___ No ___
8. Prior to this appointment, has root canal therapy been started on this tooth?
Yes ___ No ___
9. Any past trauma or injury to this tooth? Yes ___ No ___
10. If yes, describe past trauma and state the occurrence date.
__________________________________________________________
11. Is there anything else about your teeth, gums or sinuses.
__________________________________________________________
Please check the frequency, quality and intensity of your pain
LEVEL OF INTENSITY FREQUENCY QUALITY
1__ 2__ 3__ 4__ 5__ 6__ 7__ 8__ 9__ 10__ Constant__ Sharp__
Intermittent__ Dull__
Momentary__ Throbbing__
Occasional__

6. SUBJECTIVE INFORMATION
History of pain
Stimulus of pain
Frequency of pain
Severity of pain
Duration of pain
Spontaneity of pain
Location of pain
Character of pain
Alleviation of pain
OBJECTIVE INFORMATION
Visual examination
Percussion and palpation
Caries and fractured
restorations
Sinus tracts
Tooth fractures
Extensive restoration
Exposed dentin, wear facets
Periodontal disease, mobility
RADIOGRAPHIC ASSESSMENT
Tooth length, no. of roots
Calcifications, orifice location
Number of canals, radiolucencies
Resorptions, fractures
COMPARATIVE TESTING
Thermal tests
Electric pulp tests
Anesthetic test, test cavity
Transillumination
ASSESSMENT OF PULP AND PERIRADICULAR TISSUES
PLAN OF TREATMENT

7. CHIEF COMPLAINT
“Listen to your patient. He is trying to tell you what
is wrong with him”. (Sir William Osler)
Chief complaint is the history of the symptoms
noted in the patient’s own words that describes the
symptoms causing the discomfort.

8. A proper diagnosis begins with information
about the patient’s chief complaint, along with the
objective findings found through clinical and
radiographic examinations coupled with
appropriate pulp tests.
Compare the patient’s signs and symptoms and
test results to known disease entities in the
differential diagnosis and select the closest match,
which becomes the operational or working
diagnosis.

9.  An astute clinician always remains open to
further input that could modify the diagnosis
and potentially the treatment as the unfolding
of the information progresses.
 The importance of accurate diagnosis cannot
be over emphasized.

10. PAIN
The alleviation of dental pain is one of
the prime objective of the dental
profession.
Management of pain is to establish
diagnosis and treat the condition
efficiently and effectively.

11. Often diagnostic decisions concerning the pulpal
status is based on symptoms alone e.g. ” an
irreversible disease state - immediate treatment or
a reversible disease state - palliative treatment or
observation “.

12. 1. Short term sensitivity or discomfort
2. History of recent dental treatment or loss of
restoration or possible fractured cusp.
Wait & Watch approach is adopted in the following
conditions

13. Definitive pulpal treatment is indicated when
the following conditions are present
1. History of moderate or severe pain with
recurring episodes of spontaneous pain over
long period of time.
2. Painful symptoms produced by specific
stimuli such as biting /taking hot or cold
food.

14. CLINICAL EXAMINATION
VISUAL EXAMINATION:
Extra oral examination
Intra oral examination
Soft tissues:
 Color
 Contour
 Consistency
 Sinus opening

15. VISUAL INSPECTION
COLOUR
Normal crown- life like translucency
Discolored opaque – inflamed, degenerated or
necrotic pulp.
Calcified Canal – Light Yellow Hue of the Crown
Pink Tooth – Indicates Internal Resorption
CROWN CONTOUR
Wear Facets, Fractures and Restorations
Caries Examination
Diagnodent – is useful for early caries diagnosis.

16. PALPATION
Digital pressure is used to check for tenderness
in the oral tissues overlying the suspected
teeth.
Bimanual palpation is most efficient to detect
incipient swellings before it is clinically
evident.

17. PERCUSSION
Normal resonant sound on percussion indicates
good periodontal ligament
Dull sound on percussion indicates ankylosis.
Response to percussion not only indicates the
involvement of the PDL but also the extent of
the inflammation.(degree of response directly
proportional to degree of inflammation).
Chronic periapical inflammation is often
negative to Percussion.

18. Inflammation of the PDL may be caused by
occlusion, trauma, sinusitis, periodontal
disease or extension of pulpal disease .
Percussion is not a test of pulp vitality.

19. PERIODONTAL
CONSIDERATIONS
Periodontal probing should be carried out by
sounding or walking the probe around the
tooth, while pressing gently on the floor of the
sulcus.
Horizontal bone loss with generalized pocket is
not as worrisome as isolated vertical bone loss
which frequently indicates vertical root
fracture.

20. MOBILITY
Tooth mobility provides an indication of the
integrity of the attachment apparatus.
Causes may be recent trauma, crown/root
fracture, chronic bruxism, habits and
orthodontic tooth movement.
Grade I – Noticeable horizontal movement in its
socket.
Grade II – within 1 mm of horizontal movement.
Grade III – Horizontal movement greater than 1
mm and/or vertical depressibility.

21.  As we move forward in this new millennium the
science of endodontology (endodontics) has
reached its leaps and bounds. The pathway to
the most probable diagnosis was enhanced
significantly with the popularization of electric
pulp testing and availability of information from
the dental radiographs.
 “OTTO WALKOFF who took the first dental
radiograph and EDMUND KELLS used it for
diagnosis during root canal treatment deserve a
mention for their pioneering work in our field”.

22. RADIOGRAPHS
 Radiographs are an important and necessary adjunct
in Endodontics. Periapical and Bite wing
radiographs are mainly used.
 Accurate radiographic techniques and proper
interpretation are essential for sound diagnosis and
treatment.
 Radiographs are used for determining pulpal
anatomy prior to access openings.
 Establishing working length.
 Confirm master cone placement and for evaluating
the success of treatment.

23. Bite wing radiographs are helpful to
 Detect recurrent decay
 Detect the depth of pulp chamber.
Peri radicular pathosis / bone destruction is
not evident in the radiograph, until there is
significant erosion of the cortical plate because
bone loss is confined to the cancellous bone.
With a mineral content of 52% of the cortical
bone, there must be a 6.6% loss of bone
mineral in order for the lesion to become
radiographically visible.

24. Features seen in high quality periapical
radiographs (ortho radial projection) include
caries
 Sharp outline of the root
 Tooth length
 Number of roots and canals
 Calcification
 Hard tissue deposits
 Internal/External resorption
 Periapical lesions
 Perforations
 Fractures

25. CARIES
Caries progression is divided into five
radiographic grades
Grade 1 – Caries in enamel
Grade 2 – Reaches the DE junction
Grade 3 – Radiolucency extends halfway
into dentin thickness
Grade 4 – Deeper dentin
Grade 5 – involving the pulp

26. Caries Examination
 Receding pulp horn – age changes,
chronic carious lesion
 In Posterior teeth,
 Mesial Carious Lesion – more
commonly involves pulp,
 Distal Carious Lesion – Silent Killer –
takes a longer time.
 Deep caries involvement of mesial
Pulp horn causes minimal periapical
changes either in mesial/distal root.

27. The morphological features to be noted
regarding root canal anatomy
 Length – longer or shorter
 Shape – Blunder buss
Taurodontism
Dens in Dente
Root with bulbous ends
 Curved canals – Degree of curvature
X-ray exposed at 15º horizontal angle can help
visualize curvature in bucco-lingual plane.

28.  Number of canals
Always look and expect for extra canals
(Mandibular Incisor & Premolar, Maxillary
First Molar)
When large canals stop abruptly, look
for branching
 Resorption
Internal resorption – Continuous with canal
External resorption – Super imposed.
 Calcification
Can be either isolated or continuous

29.  Vertical Root Fractures
- Cannot be seen through radiographs
- Look for haziness surrounding the roots
 Transillumination
Fiber optic wand, otoscope with fiber optic
attachment or fiber optic hand piece may be used.
Composite curing lights are not recommended as they
may illuminate the entire crown and not highlight the
fracture line as with fiber optics.
 Tooth slooth
Horizontal and oblique fractures
- Two x-rays are needed to locate
these fractures
FRACTURES

30. Things to look for in radiographs
 Cervical burnout :
It is a diffuse radiolucent area on the proximal
side. Decreased x-ray absorption in that area
should not to be confused with root caries.
 Lamina dura:
Parallel – well defined
Oblique – diffuse
Thickened/dense – Heavy occlusal forces
Intact lamina dura – Vital pulp

31.  Alveolar Crest:
- Normal 1.5 mm from the C-E junction
- Crest of bone is continuous with the
lamina dura and forms a sharp angle
with junctional epithelium
- Rounding of this sharp junction
indicates periodontal disease.
 Periodontal ligament space
- Space is thinner in middle of the root
and widened near alveolar crest and
root apex.

32. NORMALANATOMIC LANDMARKS IN
MAXILLA
INTERMAXILLAR
Y
SUTURE
Seen between
incisors

33. ANTERIOR NASAL SPINE
Seen in the midline

34. NASAL FOSSA
Seen in the midline
above the anterior
nasal spine.

35. INCISIVE FORAMEN
 Symmetrical
 Variable position
 May be present at
the apex of the
central incisor
roots and even up
to the alveolar
crest.

36. SUPERIOR FORAMINA OF
NASOPALATINE CANAL
 Occasionally
appear when
exaggerated
vertical angle is
used.

37. MAXILLARY SINUS
 Close proximity of
root apices to
maxillary sinus.

38. MANDIBLE
 SYMPHISIS –
 GENIAL TUBERCLE – Seen in occlusal
radiograph.
 MENTAL FOSSA – Present in the labial
aspect of mandible.
 MENTAL FORAMEN - Seen half way
between lower border of mandible and crest of
alveolar process, usually in the region of apex
of second premolar and its position is
influenced by angulation.

39. MANDIBULAR CANAL
 Continuous with the
apex of third molar
 Distance from root
increases as it
progresses anteriorly
 Appears as tram lines in
the radiograph.

40. LIMITATIONS OF RADIOGRAPHS
 Radiograph is a two dimensional
representation of a three dimensional object.
Hence magnifying loupes are recommended
for more exact interpretation.
 Radiographic misdiagnosis – if there is only
buccal/ cervical involvement (deep caries)
 Besides diagnostic radiograph, additional
radiographs are necessary depending on
specific situations.

41. This can be overcome by the tube shift
technique, in which two films are taken in
same vertical angulation and 10 - 15º
change in horizontal angulation.
This projection helps to
 Superimposed canals can be separated
 Locate perforations
 Lesions that appear attached to the root will
move away when the projection is changed.

42. Vertical shift of tube enables to visualize the root
apices which are superimposed by the zygomatic
arch.
Other films like
 Panograms
 Lateral jaw projections
 Occlusal radiographs
are also useful in determining the three
dimensional extent of a lesion.

43. Another limitation of radiographs is
interpretation.
“All meanings, we know, depend on the
key of interpretation” - EAST

44. Radiolucency at Furcation Area
 May be due to,
 Periodontal Involvement,
 Accessory Canals,
 Cervical Pulp Horn.

45. Points to be checked during radiographic
interpretations include
 Clear films / Additional films
 Is root canal system within normal limits
(Calcifying or resorbing)?
 Is lamina dura intact or not?
 Is bony architecture within normal limits?
 What anatomical landmark can be
expected in this area?

46. Digital Radiography (RVG)
 Reduced radiation exposure – 80% less
 Immediate availability of image
 No need of processing materials
 Ability to store data
 Relief image or contrast image

47. PULP VITALITY TESTS
Assessment of vitality using routine methods
rely on the stimulation of Aδ nerve fibers and
there is no direct indication of the blood flow.
Three methods are used to stimulate the Aδ
nerve fibers
1. Thermal stimulation
2. Electrical stimulation
3. Direct dentin stimulation.

48. THERMAL STIMULATION
 Inexpensive
 The temperature used is 65.5ºC
to elicit the response
 Can use Gutta percha – (base
plate gutta percha)
 Cast metal crown restorations
are too thick to allow heated
GP to elicit response
 In such cases a rubber wheel is
used to elicit the response

49. COLD TEST
 Various materials used for cold
test are
– Cones of ice - -20ºC
– Ethyl chloride spray - - 40ºC
– Carbon- di- oxide snow –
-70ºC
Application of cold for 4 seconds
lowers the temperature to between
26 and 30ºC eliciting pain.
Within the pulp temperature is
lowered by 0.2ºC.

50. Heat causes vasodilatation and increase in intra
pulpal pressure (releases gaseous product of
proteolysis) (VAN HASSEL).
In an intact pulp specific pulpal temperature
must be reached before there is pain from heat.
Therefore, application of heat to normal teeth
gives delayed response.
In a tooth with inflamed pulp, increased intra
pulpal pressure already exists. Therefore
immediate painful response to gradual/sudden
increase in heat.

51. COLD
Cold decreases intrapulpal pressure in normal intact pulp and
there is no pain.
The pain from cold is due to hydrodynamic mechanism.
Contraction of fluid causes outward flow of fluid in dentinal
tubules, deforms Aδ nerve and an action potential is
generated.
In advanced acute pulpitis, no Aδ receptors are present. Cold
produces contraction and lowers the intrapulpal pressure to
a sub threshold level and relieves pain due to still viable C
fibers.
Pain returns within 30 – 60 seconds as intra pulpal pressure
returns to its former suprathreshold level.

52. ELECTRIC PULP TEST
 Electrolyte applied on the teeth to transmit
current
 Jelly used for ECG is ideal
 When electrolyte contacts the tooth an
electric charge is applied by pressing rheostat
button. A small charge is released initially
and increased until response is felt.
 Select control teeth – contra lateral teeth and
adjacent teeth.

54. INTERPRETATION
 If the current required to gain a response from a
test tooth is same as that needed to excite the
control – the pulp of the test tooth is considered
normal.
 If less current is required for a response –
Hyperactive
 If more current is required– delayed response/
high pain threshold
 Lack of response – Pulpal necrosis

55.  Two readings are recorded and the average
value is taken.
 “Using EPT on any tooth more than 4
times can give wrong reading due to
additive action.”

56.  Only Aδ fibers are activated by electric tests
 Aδ fibers produce initial momentary sharp
response to electric stimuli because of its
peripheral location, low threshold & greater
conduction velocity.
 Continuous constant pain is produced by the
smaller C fiber stimulation as it is associated
with tissue damage and inflammatory process.

57. DISADVANTAGES
 Battery plug in
 Electrical deficiencies
 Output current variations
 Battery run down and not delivering full
current
all these give variable results with EPT
 Molars give readings not indicative of the true
pulpal condition.

58. LIMITATIONS
 Tests are not reliable on immature teeth of
young patients as these teeth contain fewer Aδ
fibers than mature teeth and myelinated nerves
do not reach their maximal depth of
penetration into the pulp until the apex
completes its development.

59.  When comparing teeth in question with the
control teeth, pulps of the control teeth may
not be normal.
 Teeth with acute alveolar abscess may respond
positively to EPT because the gaseous and
liquefied elements within the pulp can transmit
electric charges to periapical tissues.

60.  In traumatic injuries, in the cervical
areas there will be temporary
paraesthesia of the nerves. If pulp
vitality remains, the pulp will respond
within normal limits after 30 to 60
days.

61. Current methods of stimulation of Aδ
fibers give no direct indication of the blood
flow within the pulp.
These methods are all subjective tests that
depend on patients response to stimulus as
well as dentist’s interpretation.
Assessment of the blood flow is the ideal
test for vitality.

62. Research is the primary catalyst to professional
growth and has greatly added to the
understanding of the etiology,diagnosis and
treatment of dental diseases.

63. PULSE OXIMETRY
 It is a non invasive oxygen saturation device
for recording blood oxygen saturation levels.
 Based on BEER’s law – Absorption of light
by a solute to its concentration and its optical
properties at a given wave length.
 The system consists of probe with diode that
emits light in two wavelengths.
– Red light of approximately 600 nm
– Infra red light of approximately 850 nm
 Detects presence or absence of oxygen in
blood at 760nm/860nm.

64. LASER DOPPLER FLOWMETRY
Based on the principle that reflected light from
blood flow will demonstrate a Doppler effect,
depending on the relative velocity of the blood flow
& probe.
There are two types
a) Direct laser Doppler flowmetry.
b) Indirect laser flowmetry.

65. SPECIAL TESTS
The apt test for teeth restored with composite eliciting
features of pulpitis is the cold test.
In teeth with full crown coverage hot water/ coffee test .
Wedging and staining
– methylene blue, erythrosine dye.
Selective anesthesia test
Intra ligamentry anesthesia into the distal
sulcus provides relief of pain in the affected tooth.

66.  Teeth that exhibit mixed response to pulp
testing - confirmed with Test Cavity.
 Teeth with ceramic crown – test cavity is done
on the Palatal aspect for anteriors & Occlusal
for posteriors.
Test Cavity- The Confirmatory Test

67. Difference between pulp and
periodontal disease
Pulpal Periodontal
Cause Pulp infection Periodontal
infection
Vitality Non vital vital
Restorative Deep or
extensive
Not related
Plaque/calculus Not related Primary cause
Inflammation Acute chronic
Trauma Primary or
secondary
Contributing
factor

68. DIFFERENTIAL DIAGNOSIS
The step in diagnosis to distinguish one
disease from several other similar diseases
by identifying their differences.

69. CLINICAL CHARACTERISTICS OF
CLINICAL CHARACTERISTICS OF
REVERSIBLE PULPITIS
REVERSIBLE PULPITIS
•
• Sensitivity to mild discomfort
Sensitivity to mild discomfort
•
• Short duration or shooting sensation
Short duration or shooting sensation
•
• Not severe
Not severe
•
• Infrequent episodes of discomfort
Infrequent episodes of discomfort
•
• Common causes include exposed dentin, cracked
Common causes include exposed dentin, cracked
restorations, recently placed restorations, initial
restorations, recently placed restorations, initial
carious attack or rapidly advancing caries, altered
carious attack or rapidly advancing caries, altered
occlusion
occlusion
•
• Could result in irreversible pulpitis if cause not
Could result in irreversible pulpitis if cause not
removed
removed
•
• Symptoms usually subside immediately or shortly after
Symptoms usually subside immediately or shortly after
removal of the cause
removal of the cause

70. CLINICAL CHARACTERISTICS OF
CLINICAL CHARACTERISTICS OF
IRREVERSIBLE PULPITIS
IRREVERSIBLE PULPITIS
•
• Pain may be absent or present
Pain may be absent or present
•
• If present, pain is moderate to severe
If present, pain is moderate to severe
•
• Pain is often spontaneous, increasing in frequency,
Pain is often spontaneous, increasing in frequency,
often to a point of being continuous
often to a point of being continuous
•
• Pain usually lingers, especially with increasing
Pain usually lingers, especially with increasing
episodes
episodes
•
• Thermal stimulation often elicits severe lingering pain
Thermal stimulation often elicits severe lingering pain
•
• Pain radiates or is diffuse or may be localized
Pain radiates or is diffuse or may be localized
•
• History of trauma, extensive restorations, periodontal
History of trauma, extensive restorations, periodontal
disease or extensive recurrent caries is present.
disease or extensive recurrent caries is present.

71. CLINICAL CHARACTERISTICS OF
SUB - ACUTE PERIRADICULAR
PERIODONTITIS
 Slight tenderness to biting or percussion
 No lesion present on radiographs

72. CLINICAL CHARACTERISTICS OF
CLINICAL CHARACTERISTICS OF
ACUTE PERI RADICULAR
ACUTE PERI RADICULAR
PERIODONTITIS
PERIODONTITIS
•
• Pain to biting or percussion
Pain to biting or percussion
•
• No thickened ligament space or lesion
No thickened ligament space or lesion
present
present
•
• Tooth may be mobile
Tooth may be mobile
•
• Often tender to palpation
Often tender to palpation

73. CLINICAL CHARACTERISTICS OF
CLINICAL CHARACTERISTICS OF
CHRONIC PERI RADICULAR
CHRONIC PERI RADICULAR
PERIODONTITIS
PERIODONTITIS
•
• Patient asymptomatic
Patient asymptomatic
•
• If sinus tract present, referred to as
If sinus tract present, referred to as
suppurative
suppurative
•
• Percussion produces little or no discomfort
Percussion produces little or no discomfort

74. CLINICAL CHARACTERISTICS OF
CLINICAL CHARACTERISTICS OF
ACUTE ALVEOLAR ABSCESS
ACUTE ALVEOLAR ABSCESS
•
• Severe pain with biting, percussion and
Severe pain with biting, percussion and
palpation
palpation
•
• Tooth elevated in the socket
Tooth elevated in the socket
•
• Tooth very mobile
Tooth very mobile
•
• Swelling may be present
Swelling may be present
•
• Often systemic symptoms present
Often systemic symptoms present

75. CONCLUSION
 With proper integration of clinical and
radiographic factors, in an environment
that minimizes the shackles of bias, the
wise and prudent clinician will be able to
assess both the process and completed
treatment.