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DIAGNOSIS IN ENDODONTICS .pptx
- 1. DIAGNOSIS IN ENDODONTICS -By Dr.Manjiri Honap Departmentof Conservative Dentistry and Endodontics
- 2. Learning Objectives Diagnosis Diagnostic method Medicalhistory Dental history Subjective symptoms Clinical observations Clinical tests
- 3. Diagnosis ‘The art andscience of detecting deviations from health and the cause and nature there of’ Glossary of Endodontic terms. 7th ed. Chicago: American Association of Endodontists;2003
- 4. Diagnostic method Dental history/ Medicalhistory METHODS Pulp testing Palpation Percussion Evaluation of pain signs/ symptoms DIAGNOSTIC APPROACHES Bite test Test cavity Staining/ Transillumination Selective anesthesia Radiography Newton et al. JOE- Volume 35, Number 12, December 2009
- 5. Dental history Chief complaint& its history When was it lastrestored? Pulp capping/ Pulpotomy/large restoration in the same Sharp blow/accident Swelling/ gumboil Drainage
- 6. Subjective symptoms Is thepain stillpresent? What type? (Sharp/dull) Throbbing? Intermittent/Continuous? Aggravated by: cold, heat,pressure, mastication, lying down, sweet, sour? How long does itlast?
- 7. Clinical Tests Routine Diagnostictests: 1. Percussion 2. Palpation 3. Mobility 4. Periodontal evaluation 1. EPT 2. Thermal tests 7. Occlusal evaluation 8. Radiograph Tests for selected Diagnostic Situations: 9. Test cavity preparation 10. Anesthetic test 11. Transillumination 12. Bite Test 13.Staining 14.Gutta percha point tracing with radiograph
- 8. Palpation Vestibular region: apicalregion of theroot tips Tenderness, swelling, fluctuation, hardness, crepitation Tip of indexfinger
- 9.
- 10. Periodontal probing Narrow isolatedprobing defects: Sinus- like trap followingperiapical pathosis Vertical groovedefect Crackedteeth Vertical rootfractures External rootresorption
- 11. Tests for CrackedTooth Syndrome Transillumination Fiberopticlight Coronal cracks/ vertical rootfractures Minimal backgroundlighting Light placed on varied surfacesof coronal tooth structure/ root after flap refection
- 12. Dye staining Dye penetratesfractureline Demonstratesfractures Apply – internal surfaces ofcavity preparation/ access opening Iodine/ methylene bluedye
- 13. Bite test Wooden stick-opposingteeth Toothslooth Patient bites down & pain elicited upon release
- 14. Pulp tests *Ideal technique:non invasive, painless, standardized, reproducible, reliable, inexpensive, easily completed & objective *Chambers. 1982 Pulp sensibility tests Thermal tests Electric pulp tests Test cavity Pulp vitality tests Laser doppler flowmetry Pulse oximetry
- 15. Clinically Normal pulp •I m m e d i a c y, i n t e n s i t y, & d u r a t i o n o f r e s p o n s e • Mild to moderate - transient responseto cold & electrical stimuli • Response subsides in few secondson removal of stimulus • Do not usually respond to heattests
- 16. Reversible pulpitis Thermal stimuli(cold)- sharppain Subsides as soon as the stimulusis removed/ in few seconds
- 17. Irreversible pulpitis Thermal changes(cold): sharp pain ,dull prolonged ache- last upto an hour or so
- 18. Pulp necrosis Significant relationbetween lackof response & pulp necrosis No response with EPTs & thermaltests
- 19. Thermal tests Often inappropriatelyreferred toas ‘Vitality tests’ More reliable thanEPT Inexpensive & easy-to- useequipment Patient’s painreproduced
- 20. Thermal tests- Rationale Sensoryresponse: not bytemperature changes in receptors Hydrodynamic movement offluid: dentinal tubules- A fibers Cold- faster A fibers: sharp localized pain Heat- slower C fibers: dull long lastingpain Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
- 21. Thermal tests • Initialcold sensitivity • Heat sensitivity- continued pulp deterioration • Disappearance of cold sensitivity • Cold stimuli might relieve heat induced pain
- 22. Cold tests Ice sticks 0oCtemperature Not accurate: adult posteriorteeth Secondary/ reparative dentindeposition Testing under crowns/splints Application- 5s or untilpain, Easy to use & rapidresults Disadvantage: less effectivestimulation Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
- 23. Cold tests Refrigerant sprays Dichlorodifluoromethane(DDM) Tetrafluoroethane(TFE)Green Endo- Ice(-26oC) Propane butane mixture(PBM) Propane , Butane Isobutane - Endo frost- 50oC Ethyl chloride spray – Chloroethane -- 12.3oC less effective than dry ice
- 24. Cold tests Carbon dioxide snow/ Dry Ice Charles Thilorier-1835 Dentistry: Back-1936 Apparatus modified by Obwegser& Steinhauser 1963: pencil like form -78oC; -56oC directapplication Rapid response: <2s Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
- 25. Cold tests Cold waterbath Tooth/ group of teeth : isolatedwith rubber dam Iced water syringed ontotooth Effective: simultaneous bathing ofentire crown Effective with full coveragerestorations Better than ice sticks & no armamentarium than rubber dam Timeconsuming
- 26. Heat tests Heat: fluidexpansion-A fibers Inflamed pulp: C-fibers; lastingresponse Acutely inflamed/ partially necroticpulp Low diagnostic accuracy- not usedas single method
- 27. Heat tests Heated GP( Grossman’s method) Warmed sticks of GP(120-140oC) Iight coating of petroleumjelly GP stick warmed overflame till glistening Warmed hand instruments Difficult to control temperature & safety problems Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
- 28. Heat tests Frictional heat Rubbercup-prophylaxis Buccalsurface Best, easiest &safest Goldcrown Seldom usedtoday
- 29. Heat tests Hot waterbath Similar to cold waterbath Temperature graduallyincreased Begin with most posterior andproceed until positive response Greater thermalchange PFMcrowns Time consuming & patientcooperation
- 30. Heat tests Electrical heatsources Touch ‘N Heat/ System B-150oC Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010 Castelucci. Endodontics Vol.1
- 31. Heat tests Difficult tocontroltemperature Concerns of damage to healthy pulp:not with <5 s application (Rickoff et al 1988) Reproducible results notobtained Lack of response in bulkierteeth Less consistent stimulus Limited value: posterior teeth &under splints , temporary crowns
- 32. Value of diagnostictests Heat: relatively high sensitivity;but least accurate being the least specific Cold test: more accurate thanEPT
- 33. Remember.. Inform patient ofthe nature oftests Handsignals Stimulus removed after 5-6s Refractory period after coldtest
- 34. Incisal- anterior &incisal aspect of mesiobuccal cusp: posterior (Trope & Debelian 2005) Ideally be tested on allsurfaces Several adjacent, contralateral & opposing teeth tested
- 35. Pulp sensibility tests Preferredsequence: Opposin g teeth Presumably healthy teeth- same quadrant Most suspiciou s tooth • Disease free contralateral control tooth • Opposing tooth • Presumably healthy teeth in same quadrant • Most suspicious teeth
- 36. False responses False negativeresults: Normal pulps that do not respond to tests Calcification: no response to cold;may respond to high value of current in EPT Premedication Recenttrauma Immatureapex RCT teeth: not expected torespond Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
- 37. False responses Extensiverestorations Pulp protectingbases Highpainthreshold Activation of fixed orthodonticappliances Psychoticdisorders Defective EPT device/discharged batteries/ poor electrical contact
- 38. False responses False positiveresults: Necrotic pulps responding to tests Conduction of current to adjacent gingival & periodontal tissues (avoided with reasonable current strength & proper techniques) Moist gangrene, partially necrotictissue, infected pulp Breakdown products of localized necrosis
- 39. False responses Calcified toothstructure conductingto tissue apical to an area of necrosis Current conducted to adjacent teeth through metallic restorations (avoided by rubber dam / celluloid strips between teeth) Inflamed pulp tissue in one canal of a multirooted teeth with other canals & chamber necrotic Anxious/ youngpatient
- 40. Electric Pulp Test- Rationale Current sufficient to overcome the resistance of enamel & dentine- stimulate A fibers Sensation felt with gradually increasing level of current: pulp responsive/ partially alive Pantera et al. 1993
- 41. EPT- Rationale A fibers:brief sharp sensation/ tingling *No blood flow- pulp becomes anoxic&A fibers cease to function *Pitt Ford & Patel 2004
- 42. Limitations 1. Subjective; measureonly nerve supply 2.Thermal tests: not effective in substantial secondary dentin formation 3.Unreliability of tests: Immature apices, traumatic injuries, more subjectivity in the young 4.No correlation with the histologic status (Contrasting results: Hill, 1986) 5.Extensive restorations, pulp recession, pulp calcification Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
- 43. Variations in reading/False response Failure to complete the circuit Equipment problems Probeplacement Interfacemedia Patient related factors Tooth characteristics Restored teeth Dentition Supporting tissues Apex maturation Repeated trials
- 44. False positive response Necroticpulp responds totesting. Stimulation of adjacentteeth/ attachment apparatus The response of vital tissue inmultirooted tooth with pulp necrosis in one or more canals Patient interpretation:subjectivity William T. Johnson. Colour Atlas of Endodontics
- 45. False negative response Vitalpulp that does not respondto stimulation Inadequate contact Toothcalcification Immature apex Traumaticinjury Subjective nature of thetests Elderly patients – regressive neuralchanges Analgesics forpain Traumaticinjury
- 46. Test cavity Non localized,acute diffuseradiating pain Cavity prepared in the tooth:without anesthesia Unreliable; response even in necroticpulp Response unreliable: anxiety Invasive &irreversible - Not justified in modernpractice
- 47. Laser Doppler Flowmetry Jafarzadeh.IEJ, 42, 476- 490,2009 Optical measuring method- number & velocity of particles conveyed by a fluid flow to be measured Laser light is transmitted to the pulp by means of a fiber optic probe
- 48. Pulse Oximetry Effective, objectiveoxygensaturation monitoring technique - intravenous anesthesia Consistently determines the level of blood oxygen saturation of the pulp - pulp vitality testing More sensitive & specific compared to cold tests & EPT Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009
- 49. Ultraviolet light/Fiberoptic Fluorescent Spectrometry Fluorescence Vitalteeth fluoresce normally; necrotic&RCT teeth do not –Foreman Lighting in the operatory fullysuppressed Fluorescence from the pulp -substantially lower than the healthy and decayed dentin fluorescence. Healthy and decayed dentinpatterns differentiated Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
- 50. Anesthetic test L/A: painfularea Block/infiltration/intraosseous Vague location ofpain Non odontogenic pain:Myocardial infarction
- 51. Ultrasound Compliment conventionalradiography High resolution,3D images-inner macrostructure of the tooth Detects cracks in a simulated humantooth Detect vertical root fractures – in both vital&nonvital teeth Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
- 52. Ultrasonic Doppler Imaging Bloodcirculationdetected Distinguish vital teeth from root- filled teeth: Promising tool- traumatically injuredteeth Power Doppler associated with color Doppler – improved sensitivity to low flow rates Non vital tooth Yoon et al. JOE- Volume 36, No.3, March 2010 Vital tooth
- 53. RADIOGRAPHY-Little value :assess pulp status Presence &extent of carious lesions Vital pulptherapy Calcifications Resorptions Periradicular radiolucencies Tracingfistulous tracts Thickness ofPDL Periodontal disease Root & pulpspace anatomy PreviousRCT
- 54. Diagnosis: never basedsolely on radiographic finding
- 55. Cone Beam Volumetric Tomography Firstused in dentistry- Mozzo P et al 1998 Proximityto anatomic structures Rootcanal anatomy
Editor's Notes
- #10 Firm digital pressure/ handle of instrument like mouth mirror: tap in a vertical direction Patient bite on Tooth Slooth/ Cotton swab
- #11 Endodontic & periodontic lesions mimic each other concurrently Record probing depths: periodontal health & prognosis Entire circumference probed
- #15 Pulp nerve fibers respond – external stimulus Thermal/ Electrical / Direct dentine stimulation Do not indicate the health status & does not quantify the degree of disease
- #18 EPT: not of value
- #24 Convenient and esiest to use Applied to middle third of the facial surface
- #47 Young teeth: immature roots- invasive nature questioned No further information than thermal & EPT Not justified in modern practice