chairside investigation in dentistry

1. AFSAL S.M
1st MDS

2. CONTENTS
 Introduction
 Classification
 Chairside investigations
 Conclusion
 Reference

3. INTRODUCTION
Investigations are the extension of physical examination in which tissue, blood and
other specimens obtained from patients are subjected to various examinations.
Investigation are done for the diagnosis of the disease and to do the treatment plan
accordingly.
Investigations of a patient include :
1. Chair side investigations
2. Radiographic investigations
3. Laboratory investigations
a) hematological b)biochemical c) immunological

4. CHAIR SIDE INVESTIGATIONS
 Chairside investigations are those simple test and examination
procedures perfomed near the chairside and the results are interpreted
at that time

5. CLASSIFICATION
Classification of Chairside Investigations in dentistry
2)Test for detection of vascular lesions
1) Diascopy
3)Carious Detection Test
1)Caries Dyes
2)Optical Transillumination
3)Electrical resistance
4)Quantitative Laser auto Fluorescence
5)Endoscopevideoscope
1)Pulp vitality tests
1)Thermal test
2)Electric pulp testing
3)Other tests
a. Laser Doppler flowmetry
b.Pulse oximetry

6. 5)Investigation for Maxillary sinus
1) Transillumination Test
6)Test for Xerostomia
1) Tongue blade sign
2) Lip stick test
4) Test for detection of potentially
malignant lesions and conditions
A)Vital staining
1)Toluidine blue staining
2) Lugol’s iodine
3) Methylene blue
4) Rose Bengal
B)Light Based Detection System
1)Flourescence spectroscopy
2)Chemiluminescence

7. 7) Test for periodontal diseases
1)Periotemp
2)Halimeter
3)Periotest
4)Plaque disclosing agents
5)Perioscopy
6)Fremitus test
8)Investigations for habits
1)Butterfly Test
2)Water in mouth test
3)Double sided mouth mirrors
9)Investigation for TMJ and muscles of mastication
1)Electromyography
2)Gnathodynamometer
10)Test for epithelial lesions
1)Nikolsky Sign
2)Auspits Sign
3)Asboe-Hansen Sign

8. PULP VITALITY TEST
1. Thermal
- Heat
- Cold
2. Electric Pulp Testing
3. Laser Doppler Flowmetry
4.Pulse oximetry

9. THERMAL TESTS
 These tests involve the application of cold and heat stimuli to a tooth,
to determine sensitivity to thermal changes. Although both are tests of
sensitivity, they are actually conducted for different diagnostic reasons.
 A response to cold usually indicates a vital pulp, regardless of whether
that pulp is normal or abnormal.
 In contrast, an increased response to heat is suggestive of pulpal or
periapical pathology that may require endodontic intervention

10. INDICATIONS
a) Diagnosis of endodontic pathology
b) Localisation of tooth pain
c) Differentiating between odontogenic and non-odontogenic pain
d) Assessing pulpal status following dental trauma
e) Establishment of pulpal health prior to prosthodontic treatment

11. Heat Test
Indications
a) When patient complains of pain upon contact with hot drink/food
b) When difficult to localise pain
 Materials Used:
a)Hot water
b)Hot Burnisher
c)Gutta percha
d)Polishing rubber disc

12. Procedure:
 Gutta percha stick is heated in a flame until it becomes shiny
and sags and is applied to the suspected tooth
 Tooth surface is lightly coated with vaseline to prevent the
sticking of gutta percha
 First a normal contralateral tooth should be tested and then the
affected tooth is tested

13. Cold Test
INDICATIONS
a)In younger permanent tooth with less developed apices
MATERIALS USED:
 Ice
 CO2 snow
 Ethyl Chloride spray

14. PROCEDURE
 Excess cold may cause pulpal damage or crazing lines in the enamel
 Begin with the most posterior tooth and proceed towards the anterior
teeth because such sequence will prevent melting of ice water from
dripping in a posterior direction and possible excitation of non tested
tooth by giving false response

15. ELECTRIC PULP TESTING
 Pulp testers are designed to elicit response by electrical excitation of
neural elements in the pulp
Technique:
 Describe the test to the patient in such a way that will reduce anxiety
and will eliminate a biased response
 Isolate the area of teeth to be tested with cotton rolls and saliva ejector
and air dry all the teeth
 Apply an electrolyte on the tooth electrode
and place it against the dried enamel of the
crowns on the occlusobuccal or incisolabial
surface

16.  It is important to avoid contacting any restoration in the tooth or the
adjacent gingival tissue with the elctrolyte or the elctrode or else this
would cause a false and misleading response
 Retract the patients cheek away from the tooth electrode with the free
hand
 When gloves are used circuit is closed by placing a finger on metal
electrode
 Turn the rheostat slowly to introduce minimal current into the tooth and
increase the current slowly
 Ask the patient to indicate when sensation occurs by using such words as
tingling or warmth
 Record the result according to the numeric scale on the pulp tester

17. False positive response:
 Conductor/electrode contact the gingiva
 Patient anxiety
 Liquefaction necrosis
 Inadequate isolation
 Multirooted tooth
False negative response:
 Patient premedicated with analgesics,narcotics, alcohol tranquilizers
 Recently traumatized tooth
 Excessive calcification in the canal
 Recently erupted tooth with an immature apex
 Patients high pain threshold

18. LASER DOPPLER FLOWMETRY
INDICATIONS
 Estimation of the pulpal vitality
 Pulp-testing in children
 Periapical radiolucencies may have nonendodontic origins
 Monitoring of reactions to electrical or thermal pulp
stimulation.
 Monitoring reactions to orthodontic procedures.

19. PROCEDURE
 The technique depends on the Doppler principle whereby light from a
laser diode incident on the tissue is scattered by moving RBCs and as a
consequence, the frequency is broadened.
 The frequency broadened light, together with laser light scattered is
photo detected and the resulting photocurrent processed to provide a
blood flow measurement.
 LDF is an optical measuring method that enables the number and
velocity of particles conveyed by a fluid flow to be measured.

21. LIMITATIONS
 Too expensive a device for use in a dental office.
 The sensor should be maintained motionless and in constant contact
with the tooth for accurate readings.
 The laser beam must interact with the moving cells within the pulpal
vasculature.

22. PULSE OXIMETRY
 Compared to laser Doppler flowmeters, pulse oximeters are relatively
inexpensive and commonly used in general anaesthetic procedures
 The term oximetry is defined as the determination of the percentage of
oxygen saturation of the circulating arterial blood
 Oxygenated haemoglobin and deoxygenated haemoglobin are different
in colour and therefore absorb different amounts of red and infrared
light

23. Advantages
Effective and objective method of evaluating dental pulp vitality.
 Useful in cases of impact injury where the blood supply remains intact but the
nerve supply is damaged.
 Pulpal circulation can be detected independent of gingival circulation.
 Pulp pulse readings are reproducible.
 Smaller and cheaper commercial oximeters are now available for routine clinical
use in an average dental office.
Drawbacks
 Background absorption associated with venous blood and tissue constituents is
not differentiated.
 Probes should be specific for the anatomy of a tooth as the oxygen saturation
values from the teeth routinely register lower than the readings from the
patient's finger

24. PROCEDURE
The system consists of a probe containing a diode that emits light in two
wavelengths: red light of approximately 660 nm and infra-red light of
approximately 940 nm.
A silicon photo detector diode is placed on the opposing surfaces of the
tooth, which is connected to a microprocessor.
The probe is placed on the labial surface of the tooth crown and the
sensor on the palatal surface.
Ideal placement of the probe is in the middle third of the crown.

25. DIASCOPY
 It is a specific examination technique whereby the tissue examined is
compressed by a glass slide or a wafer of clear acrylic
 To determine whether a lesion is vascular or not
 Blanching – varices,telangiectasia,hemangioma
 Non blanching- localised pigmentation,hematomas,ecchymoses
TEST FOR DETECTION OF VASCULAR LESIONS

26. CARIES DETECTION TEST
 Caries Dyes
 Optical Transillumination
a) FOTI
b)DIFOTI
 Electrical resistance
 Quantitative Laser auto Fluorescence
 Endoscopevideoscope

27. CARIES DYES
Caries detector dyes have been developed to further help
the diagnosis and removal of dental caries, by differentiating between
infected and affected dentin.
Intended to enhance complete removal of infected carious dentin without
over-reduction of sound dentin

28. Dye stains only infected dentin
“painless” caries removal technique without local anesthetic.
The use of dyes is based on the fact that increased porosity- development of
capillary like microvoids is the earliest change in carious lesions.
Dyes used to detect Enamel Caries---
Calcein, Zyglo ZL-22
Dyes used to detect Dentinal Caries---
Basic Fuschin, Acid Red system, 9-Aminoacridine
Procion dyes, produce irreversible staining , which would be clinically
unacceptable.

29. FIBRE OPTIC TRANSILLUMINATION
 Principle carious lesion has a lowered index of light transmission
 After drying the tooth, a fiberoptic probe can be placed in the buccal or
lingual embrasure directly beneath the contact area between two
adjacent teeth
 If caries is present, it is evident as a dark shadow beneath the marginal
ridge

30.  ADVANTAGES:
No hazards of radiation
Non-invasive methods
Simple and comfortable
 DISADVANTAGES
Observer variations
No permanent record of findings
Difficult to probe in certain areas

31. DIGITAL FOTI
 This is a relatively new technique which combines FOTI and a digital
CCD camera
 Images captured by the camera are sent to a computer for analysis,
which produces digital images that can be viewed

32. ELECTRICAL RESISTANCE
When an electric current passes through a material ,the electrical
properties of this material determine the extent to which the current is
conducted.
Biomaterials with high concentration of fluids and electrolytes are more
conductive than materials with low concentrations.

33.  immature, porous enamel is more conductive than mature
enamel, and that dentin is more conductive than enamel

34. Caries
Demineralisation of enamel porosity
Saliva fills these porosities
Pathway for conduction

35. QUANTITATIVE LASER AUTO FLUORESCENCE
 QLF uses a halogen lamp with a blue light (370 nm) that is emitted
from a handpiece and causes tooth to fluorescence (yellow-green).
 Image is captured with a CCD
 Enhances early detection of carious lesions

37. DIAGNOdent
 When red light with a frequency of 655 nm is applied, caries induced changes in
teeth lead to increased fluorescence (Hibst and Gall, 1990s).
 The first laser fluorescence device, DIAGNOdent 2095 (KaVo, Biberach,
Germany), was developed in 1998
 Is based on the emission of a red light, with a wavelength of 655 nm, through a
diode laser

38. PROCEDURE
A laser probe is used to scan over the fissure area in a sweeping motion. Two
optical tips are available: tip A for occlusal surfaces, and tip B for smooth
surfaces
affected enamel, light will be diffracted and dispersed resulting in the
tissue autofluorescence, or fluorophores present in the caries lesions
This fluorescence is collected at the top of the handpiece and transmitted
back to the DIAGNOdent unit
The fluorescence is processed, converted into an acoustic signal and
displayed as an integer that ranges from 0 to 99

39. CRITERIA TO ASSESS CARIES PROGRESSION
 5-25 --- initial lesion
 >25 ----early dentinal caries
 >35----advanced dentinal caries
Recent cut-off values
 0-13 no caries
 14-20 enamel caries -advised preventive care
 21-30 dentine caries
 >30 -operative care advised

40. ADVANTAGES:
 Reliable method for diagnosis of early occlusal caries
 Convenient and fast method
DISADVANTAGES:
 Expensive
 Cannot differentiate between caries, hypoplasia, stains and calculus
 Cannot differentiate between active or inactive lesions

41. ENDOSCOPE/VIDEOSCOPE
 A blue light (400-500 nm) is used to excite Fluorescence with in the
tooth.
 Difference seen in fluoresced tooth is viewed through a specific broad
band gelatin filter
 White spot lesions appear darker
than enamel.

42.  Advantage :
5-10 fold magnification
 Disadvantage :
Requires meticulous drying and isolation.
Time consuming
Additionally a camera can be used to store the
imageVIDEOSCOPE
A miniature colour video camera is mounted in a
custom made metal holder. Thus image is directly
viewed on a television screen.

43. VITAL STAINING
 Simple, cheap, sensitive, and efficient.
 Can enhance lesion characteristics, identify satellite or clinically non-
apparent lesion sites, and assist in the choice of site and the timing of a
biopsy.
 Toluidine blue staining
 Methylene blue staining
 Lugol’s iodine staining
 Rose bengal staining
TEST FOR DETECTION OF POTENTIALLY
MALIGNANT LESIONS AND CONDITION

44. TOLUIDINE BLUE STAINING
 Basic thiazine metachromatic dye
 High affinity for acidic tissue components
 It stains tissues rich in nucleic acids Dysplastic and neoplastic cells
contain more nucleic acids than normal cells
 Moreover, malignant epithelium may contain intracellular canals that are
wider than those of normal epithelium, facilitating penetration of the dye
(Epstein et al. 1992).

46. METHYLENE BLUE STAINING
 Was first used in detecting oral mucosa lesions in 2007
 Stains tissue with large quantities of nucleic acids
 Useful for screening oral cancer in high-risk individuals, and shows
high sensitivity in detecting oral PMDs
 Riaz et al

47. LUGOL’S IODINE STAINING
 Mechanism  iodine-starch reaction
 is visualized by a color change.
 The loss of cellular differentiation and the enhanced glycolysis in
cancer cells do not promote the iodine-starch reaction.
 normal mucosa stains brown or mahogany due to its high glycogen
content,
 while dysplastic and cancer lesions do not stain, and appear pale
compared with the surrounding tissue

48. ROSE BENGAL STAINING
 4,5,6,7-tetrachloro-2′,4′,5′,7′tetraiodo-derivative of fluorescein.
 widely used to diagnose ocular surface disorders
 It stains desquamated ocular epithelial cells, dead or degenerated cells,
but not healthy epithelial cells
 Du et al. in 2007 132 patients RB staining detection of epithelial
dysplasia in oral leukoplakia, lichen planus, and leukokeratosis.
( Int J Cancer 2007 May 1;120(9):1958-63.)

49. LIGHT BASED DETECTION SYSTEMS
Mucosal tissues undergoing abnormal metabolic or structural changes
have different absorbance and reflectance profiles when exposed to
various forms of light sources, enabling the identification of oral
mucosal abnormalities

50. CHEMILUMINESCENCE
 “Emission of light from a chemical reaction “
 A nontoxic blue-white chemiluminescent light is shown into mouth
and tissue reflectance is observed.
 dysplastic tissues “aceto white.”
 ViziLite, ViziLite Plus, Microlux/DL
and Orascoptic DK.
 More accurate than toluidine blue
staining.

52. Contains
 a vial of 1% acetic acid solution
 a capsule
 a retractor
Results:
“ white”positive
after a one-minute rinse with 1% acetic acid solution
 ViziLite pluscontains a TB staining solution
improving the specificity
specific wavelength is absorbed by normal cells and reflected
by abnormal cells that have a higher nuclear-cytoplasmic ratio

53. Flourescence spectroscopy:(VEL
Scope )

54. VEL Scope
 Hand held device
 Enhance the visibility of oral mucosal abnormalities by activating
tissue autofluorescence.
 Fluorophores
nicotinamide adenine dinucleotide
flavin adenine dinucleotide in the epithelium
collagen cross-links in the stroma.

55. TRANSILLUMINATION TEST
A light is shined against the sinuses.Normally
the sinus appears hollow and the light shines
through giving a reddish glow.
When inflammed and blocked with
ecretions and the light fails to shine
through and the sinus appears opaque.
INVESTIGATION FOR MAXILLARY SINUS

56. TEST FOR XEROSTOMIA
1) Tongue blade sign
2) Lip stick test

57. INVESTIGATION FOR PERIODONTAL DISEASE
 Periotemp
 Halimeter
 Periotest
 Plaque disclosing agents
 Perioscopy
 Fremitus test

58. PERIOTEMP
 The PERIOTEMP measures elevated temperatures in the periodontal
pocket surrounding the teeth
 Elevated temp. degree of inflammation
presence of periodontal disease

59. HALIMETER
 Measures the level of sulfide gas found in a persons breath
 Certain drawbacks in clinical applications like some of the common
sulfides such as mercaptan are not easily recorded
 Also very sensitive to alcohol, so one should avoid drinking alcohol or
using alcohol containing mouthwashes for atleast 12 hrs prior to being
tested

60. PERIOSCOPY
 Is a procedure that uses a miniature dental endoscope with advanced
video, lighting and magnification technology that enables us to
diagnose and treat areas below the gingiva non-surgically
 A miniature camera is attached to a tiny probe and then gently placed
subgingivlly.
 The images are immediately displayed on a chairside video screen for
the clinician

61. PLAQUE DISCLOSING AGENTS
A disclosing agent is a solution which when applied
on the tooth makes visible by staining roughness
and foreign matters on the tooth
(Raybin 1943)
Dental plaque as the ability to retain a large number
of dye substances which can be used for disclosing
purposes.This property is related to
interaction,because of the polarity difference
between the components of plaque and
dyes(Gallagher et al,1977)

62. INVESTIGATIONS FOR HABITS
MOUTH BREATHING
 Butterfly Test
 Water in mouth test
 Double sided mouth mirrors

63. TMJ AND MUSCLES OF MASTICATION
 Electromyography
 Gnathodynamometer

64. GNATHODYNAMOMETER
 A gnathodynamometer (or occlusometer) is an instrument for
measuring the force exerted in closing the mouth
 works well in measuring maximal bite force and masticatory efficiency
of incisor and molar teeth

65. ELECTROMYOGRAPHY
 Provides a objective means of monitoring changes in muscle activity
 Valuable research tool in diagnosing myofacial pain

66. TEST FOR EPITHELIAL LESIONS
 1)Nikolsky Sign
 2)Auspits Sign
 3)Asboe-Hansen Sign

67. CONCLUSION
Chairside investigations form an integral part of Oral medicine. An oral
physician requires the basic knowledge of these various investigations.
The different chairside investigations give us options to narrow down to
the particular diagnosis and exclude out the differential diagnoses.
Hence investigations are very important in the diagnosis of various
types of systemic diseases and precancerous and cancerous lesions.

68. REFERENCES
 International Journal of Applied Dental Sciences 2019; 5(3): 05-07
 Int J Cancer 2007 May 1;120(9):1958-63.
 Recent advances in diagnostic oral medicine Venkatesh G. N, Atul P.,
Sunil, Arpita R. Thakur Journal of Indian Academy of Oral Medicine and
Radiology Jul-Sep 2009 Volume 21 Issue 3
 Non-Invasive Techniques for Detection and Diagnosis of Oral Potentially
Malignant Disorders.Dongjuan Liu,Xin Zhao,Xin Zeng, Hongxia
Dan,*and Qianming Chen.Tohoku J. Exp. Med., 2016, 238,165-177

69.  Caries-Detector Dyes - How Accurate and Useful Are They? Dorothy
McComb. J Can Dent Assoc 2000; 66:195-8
 Chairside Salivary Diagnostics for Oral Diseases. Susan Vogell
 Text book of orthodontics, the art and science- sixth edition by
S.I.Bhalajhi
 Understanding Electric Pulp Testing Lado EA, Caudle R, Bowers Tand
Fundora M
 Indian J Dermatol.2014 Jan-Feb;59(1):21-23

70. Thank You