The document provides a comprehensive overview of endodontic diagnosis, detailing various diagnostic methods and their applications in determining pulp health. It explains traditional and modern techniques such as thermal tests, electric pulp testing, and advanced methods like laser doppler flowmetry and infrared thermography, along with their respective advantages and limitations. Key findings indicate a comparison of the sensitivity and specificity of different tests, identifying the most effective methods for assessing pulp vitality and diagnosing dental conditions.

1. ENDODONTIC
DIAGNOSIS- PART 2
Dr. Sushmita Rane
Seminar- 7
6/02/2023

2. INTRODUCTION
• STEDMAN’S MEDICAL DICTIONARY ‘clinical diagnosis is the
determination of the nature of the disease made from a study of the
signs and symptoms of the disease.’
Latin
“Diagignoskein”
Dia : apart
Gignoskein : to learn

3. The patient tells the
clinician why the
patient is seeking
advice.
The clinician
questions the patient
about the symptoms
and history that led
to the visit.
The clinician
performs the
objective testings.
The clinician correlates the
objective findings with the
subjective details and creates a
tentative differential diagnosis.
The clinician
formulate a definitive
diagnosis.

4. EVOLUTION
Oldest tests :
visual
examination,
percussion &
palpation
Early 1900s :
X-rays, thermal
vitality tests,
EPT, mobility
tests, test cavity
& anesthetic
test.
Recent :
Pulse oximetry,
LDF, US,
Fiberoptics,
Thermographic
imaging, Crown
surface
temperature,
Photoplethysmogra
phy, RVG, CT, MRI

5. USES
 Prior to operative procedures: Used for selected teeth prior to any
restorative or orthodontic interventions, where pulp health may be
in question
 Diagnosis of pain: Identifying pulpal pain from other conditions
such as Myofascial pain dysfunction syndrome and referred pain
 Normal response to pulp testing- eliminate pulpal pathology
 Investigation of radiolucent areas: Periapical extension of pulpal
pathology

7. PULP SENSIBILITY
TESTS
 The typical tests used to assess pulps are either Thermal(cold, heat)
or electric pulp tests – These all test depends on whether the pulp
responds to the applied stimulus and hence they are Sensibility Tests

8. USES OF PULP SENSIBILITY TESTS
Assess the health status of the pulp
Locate and diagnose tooth with pulpitis
Locate and diagnose tooth with necrotic pulp
Follow up and monitor pulp after trauma
Part of differential diagnosis process

9. Necrotic pulp
Clinically normal/ Pulpitis
Pulp Response to the stimulus
Response Responds
Nature of the response
Normal
(compared to other
teeth)
Exaggerated
(Reproduces the pain that the
patient has been experiencing-
Pulpitis)
What type of Pulpitis- History,
duration, nature

10. THERMAL TESTS
• Application of heat / cold to a tooth to determine sensitivity to
thermal changes.
• A response indicates a vital pulp, regardless of whether the pulp is
normal / abnormal.
Cold testing
Heat testing

11. MECHANISM OF COLD SENSIBILITY PULP TEST
contraction the dentinal tubules
Rapid outward flow of fluid within the patent tubules.
act on the A δ nerve fibres producing sharp sensation lasting
for the duration of the thermal test.
Also, the nerve fibres will feel this change in temperature if
they are functioning normally or if there is inflammation

12. Methods of
application
PENCILS OF ICE
WRAPPING ICE IN WET GAUZE
FROZEN CARBON DIOXIDE
‘DRY ICE’ (boiling point – 72 ° C)
ETHYL CHLORIDE(boiling point –
41 ° C)
TETRAFLUOROETHANE (DDM)
(boiling point – 26.2 ° C)
COLD PULP SENSIBILITY TESTS

13.  Dry ice
 Chen and abbott reported that Dry ice sticks were the most reliable cold test
 formed in the device called Odontotest
This device uses pressurized liquid
CO2 that is forced through a small
orifice. It becomes Dry ice when it
comes under atmospheric pressure
This produces stick of dry ice.
Its temperature is -56 °C when
applied to the tooth

14. Refrigerant spray
• Endo ice- 1,1,1,2 tetrafluoroethane
• It has a temperature of about -26 °C when first sprayed but this
reduces to about-18.5 °C in the mouth
• Application- sprayed on cotton pellet then applied to the tooth
• Disadvantage- becomes liquid quite rapidly in the warm
environment of the mouth. The liquid can then flow in the
gingival region where it may be felt and misinterpretated as
being from pulp of the tooth
Ice
Used by freezing water in the local anesthetic catridge and then
applying the extruded portion to the tooth

15. HEAT PULP SENSIBILITY TEST
• Teeth with clinically normal pulp do
not respond to heat- they only respond
to heat when they are inflamed
When do we use Heat test?
patient’s chief complaint is intense
pain on having hot liquid/food.

16. METHODS
Ball burnisher Hot GP sticks
Dry rubber polishing wheel Hot water

17. Isolate the area of tooth to be tested
Warm air is directed to exposed surface of tooth and patient’s response is noted
Heat is applied to the occlusal-buccal third of exposed crown
If no response occurs, the hot substance can be moved to the central portion of
the crown or close to the tooth cervical margin
When response occurs, heat should be removed immediately
Care to be taken to avoid using excessive heat or prolonged application of heat to
tooth
Technique

18. ELECTRIC PULP TESTING
• Uses nerve stimulation.
• Objective is to stimulate a pulpal response by subjecting
the tooth to an increasing degree of electric current.
• Electric Pulp Tester (EPT) scale used : 0-64 units
• Healthy vital pulp : 11-16 units
Sequence of testing :1st contralateral tooth
2nd opposing tooth
3rd adjacent tooth
Last suspicious tooth

19. Isolate the area of tooth to be tested
Apply an electrolyte (toothpaste) on tooth and place electrode against the dried
enamel of crown’s occlusobuccal / incisolabial surface.
Turn the rheostat slowly to introduce minimal current into the tooth & increase
the current slowly. Ask the pt to indicate when tingling sensation occurs
Record the result according to the numeric scale on EPT
Repeat the procedure for each tooth to be tested
Technique

20. • In case of complete coverage crown the tip of endodontic explorer is
coated with toothpaste and placed in contact with the tooth structure
• The tip on the electronic pulp tester is placed on the explorer and
checked for response

21. Response Interpretation
Positive Vital
Negative Non vital
False negative Immature teeth, recent trauma, atrophied
pulp/calcification, poor contact with
tooth, inadequate electrolyte.
False positive Patient anxiety, multirooted teeth, contact
with metallic restoration
Delayed respose (>30units) Partial necrosis
Early/Exaggerated(10 or <) Hyperemia
Responses of EPT

22. Contraindications :
 cardiac pacemaker &
insulin pumps
 Teeth with full coverage
restorations
Disadvantages :
 Gives no indication of
state of vascular supply.
 Doesn’t measure the
degree of health /disease
of pulp.

23. • A study conducted by Peterson et al compared the ability
of thermal and electric pulp testing methods in detection of
pulp. The sensitivity of cold test was 0.83, 0.86 for heat
testing and 0.72 for EPT.
• Same study evaluated the specificity of these tests. 93% of
teeth were correctly identified by cold and EPT whereas
only 41% teeth were identified by heat tests
• Results showed accuracy of cold test to be 86%,EPT
81%,heat test 71%

24. BITE TEST
• Useful in identifying a cracked tooth or fractured cusp, when pressure
is applied in a certain direction to one cusp or section of the tooth.
• Methods used : Biting on
Orangewood stick Wet cotton roll Burlew rubber disk

25. • Many methods have been described to identify crack undermining
the cusp. But the most common and generally used are
Commercially available devices : Tooth slooth & FracFinder
• The test is repeated on each cusp and on several teeth in the region
of patients complaint

26. How to distinguish between different conditions?
Symptomatic Apical
periodontitis
Apical Abcess
Lateral periodontitis
(periodontal pocket,
swelling and tenderness on
palpation on lateral aspect)
Cracked tooth or cusp
flexure
Pain on biting
Pain on
release of
biting force

27. DYE / STAIN TEST
• Can be done individually or along with other tests.
• Used to determine the presence of crack in the surface of a tooth
& caries detection
Crack detection dyes : Methylene blue / India ink
Caries detecting dyes : 1% acid red in propylene
glycol (stains infected dentin)

28. • A small amount of dye is placed on a
small cotton pellet & crown/root is
coated with it.
• Any dye on surface is washed away &
if fracture present , dye remains in the
crack & can be observed via loupes
Technique

29. FIBEROPTIC TRANSILLUMINATION
• An FOTI device can be used to confirm the
presence of cracks underneath any restoration &
to determine the extent & depth of the cracks
• Shining a bright light on the buccal / lingual
surface of tooth.
• For a tooth that is not cracked, light will shine
through the opposite surface without any
interruption.
• Friedman & Marcus reported its usefulness for
detection of proximal caries.

30. ANESTHETIC TEST
• Restricted to patients who are in pain at the time of the test when
the usual tests have failed to identify the tooth.

31. Using either infiltration / intraligamentary injection,
inject the most posterior tooth in the suspected area.
If pain persist when the tooth has been fully
anesthetized, anesthetize the next tooth mesial to it &
continue to do so until the pain disappears

32. TEST CAVITY
• Involves drilling through enamel-dentin junction of
an unanesthetized tooth using high speed
handpiece.
• Sensitivity/ pain felt by the patient indicates vital
pulp – no endodontic treatment indicated cavity is
restored.
• No pain felt : cavity preparation continued until
pulp chamber is reached.

33. OCCLUSAL ANALYSIS
• Occlusion should be checked to
determine if the offending tooth is in
traumatic occlusion.
• Excessive occlusal forces can be the
cause of pulpal inflammation.

34. GP POINT TRACING
• Can localize Endodontic lesion to a specific tooth
• Aids in the differential diagnosis between a periodontal and endodontic
lesion
• Place a gutta percha point through the sinus/ Fistula tract and take a
radiograph

35. ADVANCED DIAGNOSTIC
AIDS

36. Laser Doppler
flowmetry
Pulse
oximetry
UV light
Ultrasound
Doppler / Color
Power Doppler
Hughes
Probeye
Camera
Infrared
Thermography
Thermocouple
Cholesteric
Liquid
Crystals
Thermistor Ultrasound
Photoplethys
m-ography
Dual
wavelength
spectrophotome
try

37. LASER DOPPLER FLOWMETRY
• Laser Doppler flowmetry (LDF) is a method
used to assess blood flow in microvascular
systems.
• 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
• Uses HeNe(632.8nm) & GaAl semiconductor
diode laser(780-820nm)

38. • Optical measuring method-
number and velocity of
particles conveyed by fluid
flow is measured
• Laser light is transmitted
to the pulp by means of
fibre optic probe

39. Laser light is transmitted through a fiberoptic
source & placed onto tooth surface
Light enters the tooth & gets absorbed by the
RBCs which lead to a shift in frequency of
scattered light
This shift in frequency doesn’t occur in
stationary objects
Proportion of Doppler shifted light is detected
with the help of a photodetector
Technique

41. a) Painless
b) Useful in traumatized
tooth
c) Used in patients who
have undergone
orthognathic surgery
d) No noxious stimuli
e) Can be used in both
adults & children
a) Technique sensitive
b) Expensive
c) Affected by
antihypertensive drugs &
nicotine
d) Not useful in teeth with
crowns/large restorations
f) Detects only coronal
blood flow of pulp

42. Ani Belcheva et al(2021)
 two groups: test group (44
traumatised teeth) and control
group (44 sound and healthy
teeth). The measurement of
Pulpal Blood Flow was
performed, using a LDF monitor
 The analysis of the LDF
outcomes in function of
diagnosis indicated that the
measurements of the traumatised
teeth were significantly higher
than those of non-traumatised

43.  This study concluded that LDF application provides dentists with
fundamental benefits in terms of an early and precise investigation of Pulpal
Blood Flow .
 In addition, LDF is a useful monitoring tool for revascularization of
traumatised teeth and reliable objective diagnostic indicator of pulp vitality.

44. PULSE OXIMETRY
• Noninvasive method to measure oxygen saturation
levels.
Sensor
2 LEDs
Red light (660nm) Infrared light (940nm)
• A pulse oximeter works by transmitting light
through translucent portion of body(eg. Finger, ear,

45. • The amount absorbed depends on the ratio
of oxygenated to deoxygenated hemoglobin
in the blood.
• On the basis of difference between the light
emitted and light received a microprocessor
calculates the pulse rate and oxygen
concentration
• It Transmits light through
translucent portion of body
• Some of this light is
absorbed as it passes through
the tissue

46. Indications:
 Recent Trauma
 Primary and immature
permanent teeth
 Patient monitoring:
sedation
Limitation:
 Intrinsic interference:
Venous blood and tissue
constituents, acidity, CO2
 Extrinsic interference
 Well adapting sensor
 Hb bound to other gases
 Extensive Restorations
 Environmental-ambient
light interference

47. MEASUREMENT OF SURFACE TEMPERATURE
THERMISTOR THERMOCOUPLE
CHOLESTERIC
LIQUID CRYSTALS
INFRARED
THERMOGRAPHY
HUGHES
PROBEYE
CAMERA

48. THERMISTOR
• The thermistor is a small, resistance thermometer with very high
sensitivity and low heat capacity.
• Researchers have stated that a vital tooth and a nonvital teeth if cooled
below room temperature it is seen that vital teeth rewarm back to the
room temperature faster than the nonvital tooth
• 2 Types
Measuring Thermistor
Reference Thermistor

49. • Banes & Hammond – evaluated accuracy of thermistor in
teeth with vital pulps & previous RCT both with & without full
gold crowns. Surface temp of RC treated teeth without full
gold crowns were significantly lower than those of with vital
pulps

50. CHOLESTERIC LIQUID CRYSTALS
• Howell et al employed color change
of cholesteric liquid crystals in
detecting pulp vitality.
• Used to show difference in tooth
temp between teeth with vital
(hotter) pulp & necrotic (cooler)
pulp.

51. The teeth in question were isolated with a rubber
dam or cotton rolls and coated with a very thin
layer of petroleum jelly.
Thin black plastic strips, approximately 3 by 8
mm, were coated on one surface with the liquid
crystals, and the uncoated surface was placed in
contact with the tooth to be studied.
The resultant colours were recorded and
correlated with the findings of cold and
electrical stimulation.
Technique

52. THERMOCOUPLE
• Thermocouples are used for measuring the tooth surface temperature.
• Brown and Goldberg et al using thermocouple found out that surface
temperature decreased in an anterior direction.
• Labial surface had lesser temperature when compared to palatal
surface.

53. • Aidin Farugi et al(2021)
• This clinical study was
designed to compare cold pulp
testing (CPT), heat pulp
testing (HPT) and electric pulp
test (EPT) with pulse oximetry
(PO), flowmetry(FM) and
thermometry (TM) in terms of
sensitivity and specificity

54. Methodology
 20 Premolar teeth in need of Root canal treatment age between 20 and 50 years
 All tests (CPT, HPT, EPT,,FM, PO and TM) were performed by a single clinician. No
response within 7 s was considered negative for both tests. The sequence of tests was EPT,
CPT and finally HPT.
 Oxygen saturation percentage was measured for determining vitality; An infrared
transmitter circuit was used for Flowmetry which detects the variations in blood volume.
 For Thermometry, temperature of two teeth was measured for each patient: the test and the
control

55.  HPT was the most accurate of all in diagnosing pulp status without
any false results
 PO was the most accurate of all vitality tests
 This study suggests that Pulp sensibility tests may be more accurate
than vitality tests and are reliable for pulp vitality assessment.

56. INFRARED THERMOGRAPHY
• Computer controlled infrared imaging system
is a noninvasive sensitive method of
measuring body temperature
• Vital pulp higher surface temp than necrotic
pulp
• Components : IR sensor, control unit, thermal
image computer, software, color monitor &
printer

57. Teeth in question are isolated with rubber dam and
cooled with stream of cold air
Symmetrical cooling of teeth of about 22°C is done
Then teeth are rewarmed to their former temperature.
Vital teeth will rewarm in 5 sec whereas non-vital teeth
take up 15 sec to rewarm.
Technique

58. Sara Mendes et al in this study(2020)
 For the study group, 33 non-vital teeth and 33
vital upper central incisors were assessed. The
inclusion criteria were: age between 20-65 years
old; negative response to the vitality tests, teeth
suspected to be in a necrotic pulpal state
confirmed by periapical X-ray.
 They concluded that the use of IRT to assess
humans anterior teeth temperature with different
pulp states may present different temperatures.
Thus, the results suggested that the use of IRT to
assess a tooth’s vitality may be an aiding tool
during a diagnostic exam.

59. HUGHES PROBEYE CAMERA
• It can detect temperature changes as small as
0.10°C.
• It can also measure pulp vitality, by
measuring blood flow in pulp.
• This consists of thermal video system with a
silicon close up lens with a resolvable spot
size of 0.023 inch.

60. UV LIGHT
• Some objects possess an unusual feature of
being able to emit light of higher
wavelength when illuminated with UV light.
This feature is called ‘Fluorescence’
• Foreman et al (1983) reported that teeth with
necrotic pulps & teeth with RCT did not
fluoresce when exposed to UV light, while
teeth with vital pulp fluoresced normally.

61. ULTRASOUND
• Ultrasound (US) is a non-invasive, inexpensive and painless
imaging method.
• Tremendous potential to compliment conventional
radiography as an imaging technique.
• High resolution : 3D images of inner macrostructures of
tooth.
• Based on the reflection (echoes) of ultrasonic waves at the
interface b/w tissues having different acoustic properties

62. Use of Ultrasound
Healing
of
periapical
lesion
Detect the
pulpal
blood flow
in vital
tooth.
Detects
cracks
Detects
Vertical
root
fractures

63. • The ultrasound apparatus incorporates
Coupling
agent
Ultrasound
probe/
Transducer
Software
with
electronic
and digital
signal
processing
units.
High
resolution :
3D images
of inner
macrostruct
ures of
tooth.

64. Device uses a transducer (crystal containing probe) (Yoon MJ et
al,2010)
US waves generated when an alternating current (3-10 MHz) is applied
to crystal as a consequence of piezoelectric effect
When the probe is moved. Ultrasound has the ability to penetrate
biological tissues and can detect the discontinuities and pathosis
Once the sound waves hits on the biological tissues it gets scattered and
reflected back which is called the echo.
The echo signals are converted to a light image of various grey shades
Technique

66. An area of tissue that causes
a considerable reflection of
ultrasound is described as
Hyperechoic
Solid lesion
Biopsy
An area where there is no
reflection of echoes,
typically within
homogeneous liquids is
Anechoic
Cystic lesion
Enucleation

67. Elisabetta Cotti et al (2020)
 Ultrasound real-time examination
is a promising tool to detect and
trace noninvasively sinus tracts of
endodontic origin.
 It produces a direct image rather
than one obtained with a gutta-
percha cone inserted into the tract.
The vascular reaction within and
around the tract can be also
observed by the 3D rendering and
the color and power Doppler
implementation.

68.  10 patients who had a lesion of apical periodontitis (AP) and
Sinus tract and 10 patients in the control group with AP without
an Sinus tract recruited in 2 endodontic practices.
 They also traced the pattern of the Sinus tracts with a computer
program.
 The images were then submitted to 2 calibrated and blinded
observers who were asked to describe the presence of AP and
Sinus tract and to trace it with the same program.
 The data obtained were compared with the clinical and
radiographic diagnosis of Sinus tract.
Methology

71. • The main application of ultrasound in
dentistry in the past years has always been
the diagnosis of pathologies of the major
salivary glands, and sialolithiasis
• This examination, due to its reduced
invasiveness and absence of radiation
• This major salivary glands may present with
symptoms such as dry mouth, dysphagia and
obstruction of duct, inflammation, or
swelling

72. ULTRASOUND DOPPLER / COLOR POWER
DOPPLER
• Ultrasound Doppler allows for the detection of the rate and direction
of the blood flow.
• Intensity of Doppler signal is represented by changes in real time on a
graph (Doppler) & also shown in form of color spots on gray scale
image (color).
Positive doppler shifts : blood moving toward transducer = RED
Negative doppler shifts : blood moving in opposite direction = BLUE

73. Vital tooth : US doppler reveals a
pulsating waveform & sound
characteristic.
Non vital tooth : Linear non-
pulsed waveform without
pulsating sound.

74. In this study, 30 patients having
inflammatory periapical lesions of
the maxillary or mandibular anterior
teeth and requiring endodontic
surgery were selected
They used conventional periapical
radiographs as well as USG with
color Doppler and power Doppler
for the diagnosis of these lesions.
 Their diagnostic performances were
compared against histopathologic
examination.
Methodology

75. Figure 1 (A-C): Periapical cyst.
A) Intraoral periapical radiograph
shows a well-circumscribed radiolucent
periapical lesion (arrow) with a partial
sclerotic border, measuring more than 1
cm in diameter.
B) USG with color Doppler and power
Doppler shows a hypoechoic,well-
contoured cavity (arrow) with no
evidence of internal vasculature
on color and power Doppler
examinations.
C)H and E stained section shows the
presence of an epithelial lining (arrow)
with underlying dense
fibrocellular connective tissue stroma

76. Figure 2 (A-C): Periapical granuloma.
A)Intraoral periapical radiograph shows
a well-circumscribed radiolucent
periapical lesion (arrow) without a
sclerotic border, measuring less than 1
cm in size.
B)USG with color Doppler and power
Doppler shows a poorly defined
hypoechoic lesion (arrow) exhibiting a
rich vascular supply on color and
power Doppler examinations.
C)H&E stained section shows
fibrocellular connective tissue stroma
(arrow) consisting of chronic
inflammatory cell infiltrate and
endothelium-lined blood capillaries with
red blood cells, fibroblasts, and
collagen fibers

77. o The difference
between the accuracy
of radiographs and
USG for the detection
of periapical cyst and
periapical granuloma
proved to be highly
significant ( P<0.001)
USG with color Doppler and power Doppler is superior to
conventional intraoral radiographic methods for diagnosing the
nature of periapical lesions in the anterior jaws.

78. DUAL WAVELENGTH SPECTROPHOTOMETRY
• This method measures oxygenation changes in
the capillary bed rather than in the supply vessels.
• Independent of pulsatile circulation
• Detects presence or absence of oxygenated blood
at 760nm & 850nm
• It is useful method for testing vitality

79. PHOTOPLETHYSMOGRAPHY
• Optical measurement technique : used to detect
blood volume changes in microvascular bed of
tissue.
• Can also be used to investigate circulatory
changes in pulp.
• Hb absorbs certain wavelengths of light, while
remaining light passes through the tooth & is
detected by a receptor.

80. Vital pulp : Pulsatile
waveforms
Non-Vital pulp : loss of
pulsatile
(Miwa et al,2002)

81. RECENT ADVANCES IN MAGNIFICATION
• ENDOSCOPE The use of the endoscope in
endodontics was first described in 1979 as an aid
in the diagnosis of root fracture of a maxillary
central incisor
• It captures images of the subgingival environment
on a real-time and has fiber optic–delivered camera
• LOUPES are magnification devices that are widely
used in dental procedures that allow easy focus on
the surgical field and that have been used to enhance
visualization of tissues and to facilitate optimal
instrument placement

82. MICROSCOPE It has also been used as a diagnostic
tool in the detection of small orifices, in vertical root
fractures and as a complementary tool in procedures
such as repair of perforations and removal of
obstacles inside the root canal.
ORASCOPY involves using the ORASCOPE, a
modified medical endoscope, for treatment in the oral
cavity. It uses fiber optics, making the instrument
lightweight and flexible.

85. CONCLUSION
• Diagnosis forms the basis of treatment. The techniques of
endodontic diagnosis are ever evolving. Careful attention to
diagnostic aids & an understanding of both their usefulness &
limitations is essential.
• The newer techniques gives more accurate and clear diagnosis
about status of the dental disease. Few systems are in their
infancy and many are based solely in laboratories, however such
technologies may prove useful in future.

86. REFERENCES
• COHEN-Pathways of the Pulp (11th Edition)
• INGLE-Endodontjcs (7th Edition).
• WEINE-Endodontic Therapy (Fifth Edition)
• Benjamin Salmon; Dominique Le Denmat (2012). Intraoral ultrasonography:
development of a specific high-frequency probe and clinical pilot study.
• Dr.Divya Pandey,Dr Pooja Chaturvedi(2020)Recent Diagnostic Aids in
Endodontics .
• Recent Advances in Endodontics Exploring theTrends in Diagnosis.(2020).
International Journal of Innovative Science and ResearchTechnology

87. THANK YOU