Sunil M Eraly Malabar Dental College and Research Centre.

1. DIAGNOSIS IN ENDODONTICS
Prof Dr Sunil M Eraly
Head of Department
Conservative Dentistry and Endodontics
Malabar Dental College and Research Centre

2. CONTENTS
• INTRODUCTION
• HISTORY
• SYMPTOMS
• EXTRAORAL EXAMINATION
• INTRAORAL EXAMINATION
• NEURAL SENSIBILITY TEST
 THERMAL TEST
 ELECTRIC PULP TEST
 TEST CAVITY
 ANESTHETIC TEST

3. • PULP VASCULARITY TEST
 PULSE OXIMETRY
 LASER DOPPLER FLOWMETRY
 DUAL WAVELENGTH SPECTROPHOTOMETRY
 TRANSMITTED LASER LIGHT (TLL)
 PHOTOPLETHYSMOGRAPHY
 LIQUID CRYSTAL TESTING
 HUGHES PROBEYE CAMERA
 XENON 133
 FIBEROPTIC FLUORESCENT SPECTROMETRY

4. • RADIOGRAPHY
• DIGITAL RADIOGRAPHY
• ADVANCED IMAGING TECHNIQUES
• CONCLUSION
• REFERENCES

5. Listen to your patient….The patient will give you
the diagnosis….
- Sir William Osler

6. INTRODUCTION
• DEFINITION
• DIAGNOSIS - The art and science of detecting and
distinguishing deviations from health and the cause
and nature thereof.
• DIFFERENTIAL DIAGNOSIS -The process of
identifying a condition by comparing the symptoms
of all pathologic processes that may produce similar
signs and symptoms. (AAE)

7. • Diagnostic procedures should follow – medical and dental
history, radiographic examination , extra oral and intra oral
clinical examination including histopathological examination
- FINAL DIAGNOSIS (1)
• Process of making diagnosis – 5 stages:
1. Patient tell the clinician why he is seeking advice
2. Clinician questions the patient about the symptoms and
history
3. Clinician performs objective clinical tests

8. 4. Clinician correlates the objective findings with the
subjective details and create a tentative differential
diagnosis
5. Clinician formulates definitive diagnosis (2)

9. • HISTORY AND RECORD:
• Case history is defined as the data concerning an individual
and his or her family and environment, including the
individual medical history that may be useful in analyzing and
diagnosing his or her case or for instructional purposes
(Grossmans Endodontic Practice, 13th edition)

10. • To avoid irrelevant information and prevent errors of
omission in clinical tests, the clinician must establish
a routine for examination.
• Case of medical condition - get clearance from the
physician (written consent)

11. DIAGNOSTIC INSTRUMENTS

12. • Chief complaint:
• Reason for consulting the clinician – important
• Clues – final diagnosis
• Should be documented in patients own words

13. • PRESENT DENTAL ILLNESS:
• Help determine severity and urgency of the problem
• History of recent dental treatment
• Questions : character of pain , location, duration….

14. • MEDICAL HISTORY:
• Proper medical history should be taken – in forms
• Baseline blood pressure and pulse should be recorded
at each visit – elevation indicate anxious patient –
may require reduced stress protocol
• Should be aware of drug allergies

15. • A simple check list for a
medical history (Scully
and Cawson)
• Anaemia
• Bleeding disorders
• Cardiorespiratory
disorders
• Drug treatment and
allergies
• Endocrine disease
• Fits and faints
• Gastrointestinal disorders
• Hospital admissions and
attendances
• Infections
• Jaundice or liver disease
• Kidney disease
• Likelihood of pregnancy
or pregnancy itself

16. • There are no medical conditions which specifically
contra-indicate endodontic treatment, but there are
several which require special care.
• Any doubt about the state of health of a patient,
his/her general medical practitioner should be
consulted before any endodontic treatment is
commenced.

17. • Rheumatic fever:
• In 2017, the American Heart Association(AHA) and
American College of Cardiology (ACC) published a
focused update to their previous guidelines on the
management of valvular heart disease.

18. 1. Prosthetic cardiac valves, including transcatheter-
implanted prostheses and homografts.
2. Prosthetic material used for cardiac valve repair, such as
annuloplasty rings and chords.
3. Previous Infective Endocarditis.((Infective endocarditis
(IE) is a microbial infection of the endothelial surface of
the heart or heart valves that most often occurs in
proximity to congenital or acquired cardiac defects.)

19. 4. Unrepaired cyanotic congenital heart disease or
repaired congenital heart disease, with residual
shunts or valvular regurgitation at the site of or
adjacent to the site of a prosthetic patch or prosthetic
device.
5. Cardiac transplant with valve regurgitation due to a
structurally abnormal valve

21. • Additional Considerations:
• The practitioner and patient should consider possible
clinical circumstances that may suggest the presence
of a significant medical risk in providing dental care
without antibiotic prophylaxis, as well as the known
risks of frequent or widespread antibiotic use

22. • Patients with previous late artificial joint infection
• Increased morbidity associated with joint surgery
(wound drainage/hematoma)
• Patients undergoing treatment of severe and
spreading oral infections (cellulitis)
• Patient with increased susceptibility for systemic
infection
• Congenital or acquired immunodeficiency
• Patients on immunosuppressive medications
• Diabetics with poor glycemic control

23. • Patients with systemic immunocompromising
disorders (e.g. rheumatoid arthritis, lupus
erythematosus)
• Patient in whom extensive and invasive procedures
are planned
• Prior to surgical procedures in patients at a
significant risk for medication-related osteonecrosis
of the jaw
(Antibiotic Prophylaxis 2017 Update. AAE)

24. Hypertension
• A sustained systolic blood pressure of 140 mm Hg or
greater and/or a sustained diastolic blood pressure of
90 mm Hg or greater is defined as hypertension.

25. BP Classification Systolic BP (mm
Hg)
Diastolic BP (mm
Hg
Normal <120 and <80
Prehypertension 120-139 or 80 - 89
Stage 1
hypertension
140-159 0r 90-99
Stage 2
hypertension
≥160 or ≥100
(Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure (JNC 7) )

27. • Stress management is important for patients with
hypertension
• Long or stressful appointments are best avoided
• Antihypertensive agents tend to produce orthostatic
hypotension as a side effect, rapid changes in chair
position during dental treatment should be avoided.

28. • Epinephrine content of 1: 100000 in anesthetic
solutions is considered safe
• No more than 3 carpules should be used at any single
appointment

29. • Drug interactions between vasoconstrictors and
antihypertensive drugs—specifically, the nonselective
β-adrenergic blocking agents
• Should avoid using gingival retraction cord that
contains epinephrine - which can be quickly absorbed
through abraided gingival sulcus tissues - resulting
in tachycardia and elevated blood pressure.

30. Ischemic Heart Disease
• Symptomatic coronary atherosclerotic heart disease often
is referred to as ischemic heart disease.
• NSAIDs be used with caution - patients who have had a
previous MI - naproxen be the drug of choice -
administered for less than 7 day
• Patients with symptoms of unstable angina or those who
have had an MI within the past 30 days - elective care
should be postponed. Avoid use of vasoconstrictor if
possible (max 2 carpules)

31. • Cardiac arrhythmia - refers to any variation in the
normal heartbeat - includes disturbances in rhythm,
rate, or the conduction pattern of the heart
• Schedule short morning appointments. Use anxiety
reduction protocols

32. • In patients taking warfarin - Review current
INR lab results (within 24 hours of
surgical procedure).
• If INR is within the therapeutic range (2.0-3.5) -
performed without stopping or altering the
warfarin regimen

33. • In patients taking dabigatran when major oral surgery
is planned:
• Review current thrombin clotting time, activated
partial thromboplastin time
• In the dental setting- only electrosurgery, ultrasonic
bath cleaners, curing lights, and ultrasonic scalers
have been shown to produce potential interference –
should not be used in patients with pacemaker

34. Patients with Joint Replacement
• Patients with prosthetic joint implants, prophylactic
antibiotics are not recommended prior to dental
procedures to prevent prosthetic joint infection.
• In cases where antibiotics are deemed necessary, it is
most appropriate that the orthopedic surgeon
recommend the appropriate antibiotic regimen and
when reasonable write the prescription
(Antibiotic Prophylaxis 2017 Update. AAE)

35. Diabetes
• Healing is usually retarded
• Schedule appointments early in the morning –soon
after their meals
• Experimental and clinical studies have demonstrated
a higher prevalence of periapical lesions in patients
with uncontrolled diabetes.

36. • Pulps from patients with diabetes have the tendency
to present limited dental collateral circulation,
impaired immune response, increased risk of
acquiring pulp infection (especially anaerobic ones)
or necrosis, besides toothache and occasional
tendency towards pulp necrosis caused by ischaemia.
(Lima et al, IEJ 2013)

37. Blood diseases
• To minimize the risk of medical complications, Hb
levels should be above 11 g/dL, and the patient
should be free from symptoms.
• Patients who are short of breath and in whom Hb
levels are less than 11 g/dL, an abnormal heart rate, or
oxygen saturation less than 91% (as determined by
pulse oximetry) are considered medically unstable,
and routine treatment should be deferred until their
health status improves.

38. • Prophylactic antibiotics are often recommended for
sickle cell anemia when major surgical procedures are
performed to prevent wound infection
• Care must be given when placing rubber dam clamp –
on gingival tissues – bleeding
• Sickle cell anemia – associated with bone pain –
mimics odontogenic pain and loss of trabecular
pattern on radiographs

39. • Multiple myeloma – more mobility of tooth
• Radiation therapy – can result in increased sensitivity
of teeth and osteoradionecrosis

40. • Pretreatment Evaluation and Considerations –
• leukemia or lymphoma - the dentist should become
involved early—during the treatment planning stages
of cancer therapy
• Extraction in patients - 10 to 14 days between the
time of extraction and initiation of chemotherapy or
radiotherapy - avoiding invasive procedures if the
platelet count is less than 50,000/µL

41. • Warfarin anticoagulation therapy –continuation - for
minor oral surgery and other similarly invasive dental
procedures if the INR is 3.5 or less.
• It is estimated that for every increase of 1.0 in the
INR over 3.5, the risk for bleeding doubles.

42. Hepatitis
• Patients with Active Hepatitis -No dental treatment
other than urgent care
• If surgery is necessary, a preoperative prothrombin
time and bleeding time should be obtained and
abnormal results discussed with the physician
• Patients with a History of Hepatitis - clinical
laboratory to screen for the presence of HBsAg or
anti-HCV

43. • Nonsteroidal antiinflammatory drugs (NSAIDs),
including aspirin, and acetaminophen, as
well as codeine and meperidine, should
be avoided or their use very limited in
persons who have end-stage liver disease.
• Antibiotics - Tetracycline,Metronidazole Vancomycin
– avoided
• (Little and Falaces, Dental management of medicaly compromised
patietns)

44. • DENTAL HISTORY:
• Chronology of events that lead up to the chief
complaint
• Should include past and present symptom , trauma ,
procedures done..
• 5 basic directions of questioning : localization,
commencement, intensity, provocation and duration

45. SOAP FORMAT (Subjective Objective
Appraisal Plan) – for diagnosis
S – SUBJECTIVE O –OBJECTIVE A –APPRAISAL P – PLAN
CHIEF
COMPLAINT
EXTRA / INTRA
ORAL
EXAMINATION
DIAGNOSIS ENDODONTIC
HISTORY OF
PRESENT
ILLNESS
PULP VITALITY
TETS,
RADIOGRAPHS
ETIOLOGY PERIODONTAL
NATURE OF PAIN PDL
EXAMINATION
PROGNOSIS RESTORATIVE

46. SYMPTOMS
• DEFINED as phenomena or signs of a departure from the
normal state and are indicative of illness
• SUBJECTIVE symptoms : those experienced and reported to
the clinician
• OBJECTIVE symptoms: those ascertained by the clinician
through various tests

47. • SUBJECTIVE SYMPTOMS:
• Patients past medical and dental history consists of
subjective symptoms
• Patients chief complaint – related to pain, swelling,
lack of function or esthetics
• Include signs and symptoms, duration and intensity of
pain, and relieving and exaggerating factors.

48. 1. PAIN:
• Most common complaint – PAIN
• Pain is an unpleasant, subjective, sensational and emotional
experience associated with actual or potential tissue damage

49. • The 2 types of sensory nerve fibres in the pulp are
myelinated A fibres (A-delta and A-beta fibres) and
unmyelinated C fibres
• Ninety percent of the A fibres are A-delta fibres
located at the pulp– dentin border in the coronal
portion of the pulp and concentrated in the pulp horns

50. • C fibres are located in the core of the pulp, or the
pulp proper, and extend into the cell-free zone
underneath the odontoblastic layer.

51. Differences In Excitation Of A–Delta And C-Fibers
SYMPTOMS AND
REACTIONS
A FIBERS
MYELINATED
C FIBERS
UNMYELINATED
Conduction
Pain
Location
Cold
Heat
Ion effect
EPT
Localization
Referred pain
Excitability threshold
Hypoxia
Increase in pulp pressure
Inflammatory mediators
Hyperosmotic solutions
Fast
Sharp
PDJ
Yes
Yes
Yes
Yes
Good
No
Low 9.9 µA
No response
No
No
Yes
Slow
Dull
Core of pulp
No
Yes
No
No
Poor
Yes
High 37.4 µA
Responds
Yes
Yes
No

52. Odontogenic pain
• Kind of pain : 2 types – sharp, piercing, and
lancinating – excitation of A delta nerve fibers
• Dull, boring, gnawing and excruciating : excitation
and slower rate of transmission of C fibers

53. • Source in the pulpodentinal complex and/or
periapical tissue
• Reversible pulpitis -It is characterized by a short-
term pain on the cold, which quickly disappears after
the removal of pathological stimuli

54. • Periadicular pain - Periradicular pain is usually
caused by spreading of the infection from the pulp
into periapical tissue.
• In the PDL are proprioceptors which allow a precise
localization of the pressure-stimuli, so a periapical
process is easily diagnosed.

55. • Irreversible pulpitis, the clinical finding will contain
symptoms of both irreversible pulpitis and periapical
process (sensitivity to bite, with a dull, persisting,
pulsating pain).

56. • Referred pain:
• The term referred or reflected pain, denotes the pain
felt in the body part which is remote from the place of
stimulation or tissue damage.
• Atypical facial neuralgia- Pain usually occurs
bilaterally, in contrast to trigeminal neuralgia, which
occurs unilaterally
• The pain appears to localize itself mainly in the upper
molars

57. • Non odontogenic pain:
• Painful syndromes of the jaw which emulate
toothache are divided into :
• acute (trigeminal neuralgia, “cluster” headaches,
acute otitis media, acute maxillary sinusitis,
cardiogenic jaw-pain, sialolithiasis)
• chronic (temporomandibular joint disorders and
cheek -muscle pain, atypical facial pain, allergic
sinusitis, postherpetic neuralgia, facial pain as a result
of malignant neoplasms)

58. Fibres and their responses:
• Type of fibres to clinical pulp testing methods:
• Thermal pulp testing depends on the outward and
inward movement of the dentinal fluid, whereas
electric pulp testing depends on ionic movement.

59. • Because of their distribution, larger diameter than
that of C fibres, their conduction speed and their
myelin sheath, A-delta fibres are those stimulated in
electric pulp testing.

60. • C fibres do not respond to electric pulp testing.
Because of their high threshold, a stronger electric
current is needed to stimulate them
• Based on the hydrodynamic effect, outward
movement of dentinal fluid caused by the application
of cold (contraction of fluid) produces a stronger
response in A-delta fibres than inward movement of
the fluid caused by the application of heat.

61. • Repeated application of cold will reduce the
displacement rate of the fluids inside the dentinal
tubules, causing a less painful response from the pulp
for a short time, which is why the cold test is
sometimes refractory

62. • Continuous cold application compromises the blood
flow due to vasoconstriction of the blood vessels
anoxia
• When the application of cold is prolonged, there is a
drop in mitochondrial activity, with a fall in impulse
frequency and decreased excitability, which is
considered to be a CRYOGENIC EFFECT.
(Bender, JOE)

63. • Heat application on the other hand, has a BIPHASIC
EFFECT.
• First, the initial heat application evokes a rapid, brief
pain response due to the rapid fluid movement
caused by the sudden temperature change.
• As the heat application is continued, there is a period of
pain cessation followed by a more intense pain with a
greater frequency and a rise in mitochondria1 activity.

64. • This is presumably due to the dilation of blood
vessels caused by heat with a transient increase in
intrapulpal pressure
• This action now involves the C-fibers, which are
effected by heat. The A-delta fibers seldom cause
intense or referred pain.

65. • An uncontrolled heat test can injure the pulp and
release mediators that affect the C fibres.
• A positive percussion test indicates that the
inflammation has moved from the pulp to the
periodontium, which is rich in proprioceptors,
causing this type of localized response.
(Ashraf Abd-Elmeguid, Donald C. Yu. Dental Pulp Neurophysiology: Part 1.
Clinical and Diagnostic Implications JCDA 2009)

66. • Hyper parathyroidism – hypercalcemia
• Calcium ions have a stabilising effect
• Calcium ion increases reduce Na permeability
- lower excitability less pain
• Requires twice the electric current

67. • Hypoparathyroidism -
• Decrease in intracellular calcium – increase Na
permeability – rapid action potential
• Trowbridge et al. found that eugenol increased
potassium permeability of the nerve fiber membrane
and depressed the rate of sodium influx during
membrane excitation, thus creating a state of
hyperpolarization.

68. • The increase in potassium ions produces the anodyne
effect that follows the application of a zinc oxide-
eugenol dressing.

69. 2. LOCATION:
• Localized pain: patient point to a specific tooth or site
• Diffuse pain : patient describes an area of discomfort not a
specific site
3. DURATION OF PAIN:
 Short and specific to stimuli – pulpal pain on contact with the
irritant. Acute reversible pulpitis - pain of short duration,
specific irritant – disappear when the irritant is removed
Pain more responsive to cold

70.  Persistent and lingering : pain persists and last after
the removal of stimuli – usually irreversible
 Spontaneous pain : occurs without any apparent cause
–usually a pain of long duration – irreversible pulpitis
 Nocturnal pain : pain that changes the position of the
head awakens – irreversible pulpitis

71. • DENTINAL HYPERSENSITIVITY:
• DEFINTION : “dentin hypersensitivity is characterized by
short, sharp pain arising from the exposed dentin in response
to stimuli typically thermal, evaporative, tactile, osmotic or
chemical and which cannot be ascribed to any other form of
dental defect or pathology” (Holland et al)

72. • Hypertonic solutions activate the intradental nerves
through osmotic pressure manifested clinically by the
pain that results when saturated sucrose solutions
come into constant contact with sensitive dentin.
• The patent dentinal tubules are an important factor in
the induction of pain in sensitive dentin – stimulation
of A fibers

73. • The ionic concentration of the material also affects
the reduction of pain in sensitive dentin.
• A normally irritant substance such as potassium
chloride temporarily relieves pain because the high
concentration of potassium temporarily blocks the
conduction of nerve impulses hyperpolarization
that decreases the excitability of the nerve fibres.

74. • Clinical features:
• Common – pain
• Intensity – mild to severe
• Rapid in onset, sharp in character, short duration
• External stimuli – thermal stimuli , osmotic stimuli, acidic,
mechanical
• Most common – buccal surface of premolars, labial surface of
incisors

75. EXTRAORAL EXAMINATION
• Signs of facial asymmetry – swelling
• Palpation: cervical and submandibular lymph nodes-
firm , tender, facial swelling and elevated temperature
– infection present

76. Space infections

77. • Buccal space infection:
• Buccal root apices of maxillary PM and molar and
mandibular PM & first molar
• Roots are localized above or below buccinator

78. • Palatal abscess:
• Apices of upper lateral incisor and palatal roots of
upper premolars and molars

79. • Canine space infection – loss of definition of
nasolabial fold
• Maxillary canine, rarely maxillary first premolar

80. • Submandibular space infection:
• Mandibular molars
• Infections which exit alveolar bone on the lingual and
are inferior to mylohyoid muscle

81. • Submental space infection:
• Mandibular anteriors

82. • Sublingual space infection:
• Mandibular incisors, canine, premolar and sometimes
molars
• Superior to the mylohyoid muscles

83. • Ludwigs angina :
• When submandibular, submental and sublingual
spaces are bilaterally involved in infection
• Rapidly spreading
• Elevation and displacement of the tongue, trismus,
drooling of saliva and difficulty of breathing

84. • Facial asymmetry:
• Asymmetries of the head and neck are assessed by
standing directly in front of the patient
• Significant asymmetries should be noted

85. • Lymph node examination
• Should be palpated gently to look for tenderness or
enlargements.
• Normal lymph nodes are either not palpable, or you
may feel a lymph node that is the size and shape of a
small pea or lentil - mobile, non-tender.
• Abnormal lymph nodes are generally larger, fixed and
may be tender.

86. • Tenderness of the lymph nodes generally indicates
inflammation or drainage of infection.
• Cancer metastasis to a lymph node is often a fixed,
non-tender, firm enlargement.
• Lymphoma is another possible cause of non-tender
enlargement of lymph nodes of the neck.

87. • Submental nodes- found beneath the chin.
• The lymphatic channels from the mandibular incisors,
the tip of the tongue, and the midline of the lower lip
and chin drain into these nodes.
• Any infection in these areas would generally cause
some tenderness and enlargement of the nodes.
• These nodes tend to drain into the submandibular
nodes or directly down and across the neck to the
lower deep cervical nodes.

88. • Submandibular nodes are found grouped around the
submandibular gland near the angle of the mandible.
• Maxillary teeth and the maxillary sinus, with the
exception of the maxillary third molars; the mandibular
canines and all mandibular posterior teeth, the floor of
the mouth and most of the tongue; the cheek area; the
hard palate; and the anterior nasal cavity.

89. • Any infections in these areas tend to cause
enlargement and tenderness of the submandibular
nodes. This condition is referred to
as lymphadenopathy.

90. TMJ examination
• The function of the TM joint should be evaluated
using a bilateral technique.
• Place the fingertips over the joint and have the
patient open and close slowly, move the jaw to the
left and right and jut the chin out. Look for altered
opening and closing pathways, abnormal sounds,
tenderness and limitations in opening.

91. • Deviations -An altered pathway on opening which
comes back to the midline at maximum opening
• If the greatest distance from the midline occurs at
maximum opening it is called a deflection.
• Abnormal sounds may be heard -clicks, pops and
crepitus.
• Clicks and pops are associated with articular disk
derangement and crepitus is usually associated with
some form of arthritis.

92. • Correlate TM joint findings with the patient’s
occlusal classification and other dental findings such
as missing teeth and poorly fitting partial and/or full
dentures

93. INTRA ORAL EXAMINATION
• Determined by tests and observations by the clinician
VISUAL AND TACTILE INSPECTION
PERCUSSION
PALPATION
MOBILITY
BITE TEST
MAGNIFICATION
RADIOGRAPHY
ASSESSMENT OF PULP VITALITY

94. VISUALAND TACTILE INSPECTION
• “Three Cs”: color, consistency and contour
• HARD TISSUES:
• NORMAL CROWN : life like translucency and sparkle
• Crown contours must be checked – fractures, wear facets..

95. • Teeth that are discolored : can be necrotic ,
gangrenous pulp, internal or external resorption,
tetracycline staining, old amalgam restoration, root
canal medicaments…

96. • SOFT TISSUES:
• GINGIVA :
• Color - Healthy pink to inflamed
• Change in contour – with swelling
• Consistency – soft, fluctuant or spongy tissue
• Periodontium :
• Common periodontal probes :

97. • Williams periodontal probe
• University of North
Carolina periodontal probe
(UNC-15) – color coding at
5th , 10th , and 15th mm
• WHO probe – 0.5mm ball
end tip- color coding
between 3.5 & 5.5 mm

98. Classification of pockets :
• Gingival pocket :
• Pseudopocket
• Gingival enlargement
without destruction of
underlying periodontal
tissues

99. • Periodontal pocket :
• With destruction of
supporting periodontal
tissues
• Suprabony :
• Bottom of pocket
coronal to the
underlying alveolar
bone

100. • Intrabony :
• Bottom of pocket is
apical to the level of
adjacent alveolar bone

101. • According to the tooth surface involved:
• Simple
• Compound
• Complex

102. Endo – Perio Communications
• Pulp communicates with periodontium through apical
foramen , lateral canals and dentinal tubules

103. Classification of endodontic – periodontic lesions:
(Simon , Glick and Frank – 1972)
• Primary endodontic
lesion :
• Infection from apex of
tooth or lateral canal
and multirooted tooth
drainage - mesial or
distal aspect or affect
furcation area

104. • Multirooted tooth
drainage along areas of
furcation

105. • Drainage of pus through
gingival sulcus :
• Through the periodontal
fibers
• Narrow and deep defect
– probing

106. • Pus from the apex
penetrate the cortical
bone near apex – detach
periosteum and runs
between periosteum
underlying alveolar
bone – opens into
gingival sulcus

107. • Primary endo – drainage from sulcus , slight swelling,
slight discomfort for the patient
• Defect can be probed with GP cone or periodontal
probe – to the origin of infection

108. • Infrabony pockets –
periodontal origin
• Wide and less deep –
bowl shaped defect

109. • Tubular defect in primary endodontic lesion –
narrow and deep

110. • Long, narrow probing depth –
• Enamel Pearl – lack a true attachment – susceptible
to creation of narrow and deep pocket
• Developmental groove – palatal surface of maxillary
lateral incisor
• Vertical groove on the root surface – apical migration
of epithelial attachment -narrow deep defect - pulp
necrosis

111. • Radiograph reveals – presence of lateral radiolucency
along the entire length of root
• Necrotic pulp – radiograph shows a typical tear
shaped radiolucency

112. • Vertical fractures :
• Pockets are very narrow (1 to 2 mm) with a sulcus of
normal depth , both mesial and distal to the defect

113. • Primary endodontic lesion with secondary
periodontal involvement:
• Primary endo lesion – untreated – plaque along the
pathway of fistula – secondary formation of calculus
– onset of periodontitis
• Prognosis will depend on severity of periodontal
problem

115. • Primary periodontal lesion:
• Lesion caused by periodontal disease
• Diagnosis based on pocket probing
• Pulp test – vital pulp
• Fistula might be present
• Radiograph - bony defect along lateral aspect of
tooth
• Prognosis - depends only on periodontal therapy

117. • Primary periodontal with secondary endodontic
lesion:
• Perio lesion – destruction of attachment apparatus –
bacteria can reach pulp – pulp necrosis

119. • Coexisting primary endo and primary perio lesion:
• Both lesions with independent etiology coexist
without communicating with each other

120. • “ True” combined lesion :
• 2 diseases coexisting in the same tooth –
communicate with each other – but with independent
etiologies
(Periodontal Diagnosis and therapy : Giano Ricci )

122. FURCATION
Glickman’s classification for furcation defects:
•Grade I: Incipient lesion when the pocket is suprabony
involving soft tissue and there is slight bone loss.
•Grade II : Bone is destroyed on one or more aspects of the
furcation but probe can only penetrate partially into the
furcation. – cul- de- sac
• Grade III. Intraradicular bone is completely absent but the
tissue covers the furcation.
• Grade IV. Through and through furcation defect.

123. • Root resection :
• Grade II to grade IV furcation
• Indications (Bassaraba):
• Teeth that are of critical importance to the overall
treatment plan
• Teeth having sufficient attachment
• Good oral hygiene and low caries activity

124. • Hemisection:
• Splitting of tooth into two separate portions
• Class II or class III furcation
• Narrow interradicular zones – complication

125. • INTRA ORAL SWELLING:
• Should be visualized and palpated – diffuse or
localized, firm or fluctuant
• Swelling in anterior part of palate – mostly infection
from the apex of maxillary lateral incisor or palatal
root of max first PM
• Posterior palate – max molars

126. • Mandibular tooth with root apices superior to the
level of muscle attachment –infection exit on the
bone facial
• Sublingual space – infection spread to the lingual and
exit the alveolar bone superior to the attachment of
mylohyoid
• Tongue will be elevated and swelling bilateral
• Infection to lingual – mandibular molars –inferior to
muscle – swelling submandibular space

127. • INTRAORAL SINUS TRACT:
• Chronic endodontic infection will drain through an
intraoral communication to the gingival surface
• Tracing the sinus tract will provide objectivity in
diagnosing the location of the problematic tooth

128. PERCUSSION
• Evaluate the status of periodontium surrounding the tooth.
• The tooth is struck a quick, moderate blow, initially with
low intensity by the finger and then with increasing
intensity by using the handle of an instrument -to
determine whether the tooth is tender.
• Sensitive response – symptomatic apical periodontitis
• Pain on tapping facial surface – periodontal inflammation

130. • Percussion used in conjunction with other tests –
palpation, mobility & depressibility – presence of
periodontitis
• Patients with acute pain – mild pressure with
clinicians thumb
• Do not percuss beyond patients tolerance
• More valid response – from the body movements,
reflex pain reaction…

131. PALPATION
• Done with finger tips
• Locating the swelling over an involved tooth and
determine:
Whether the tissue is fluctuant and enlarged
sufficiently for incision and drainage
Presence, intensity, and location of pain
 Presence and location of adenopathy
 Presence of bone crepitus

132. MOBILITY AND DEPRESSIBILITY
• The mobility test is used to evaluate the integrity of
the attachment apparatus surrounding the tooth.
• The test consists of moving a tooth laterally in its
socket by using the fingers or, preferably, the handles
of two instruments

133. MILLERS INDEX:
•First-degree mobility as a
noticeable movement of the tooth in
its socket than normal
• Second-degree mobility as a
horizontal movement of the tooth
within a range of 1 mm
• Third-degree mobility as a
horizontal movement greater than 1
mm or when the tooth can be
depressed

134. • Test for depressibility consists of moving a tooth
vertically in its socket. This test may be done with the
fingers or with an instrument.
• Endodontic treatment should not be carried out on
teeth with third-degree mobility unless mobility is
reduced when pressure in the periodontium has been
relieved.

135. BITE TEST
• Useful in identifying a cracked tooth or fractured
cusp
• Also helpful in diagnosing cases wherein the pulpal
pathosis has extended into the periradicular region
causing apical periodontitis.
• Pain on biting -» Apical periodontitis
• Pain on release of biting force -» Cracked tooth

136. Tooth Slooth Frac finder

137. MAGNIFICATION
• Initially – magnification loupes
• Recently – operating microscopes
• Locating hidden canals
• Detection of cracks and fractures

138. Specificity
• Ability of a test to detect the absence of disease.
• Indicates the test’s ability to identify vital teeth.
• It is defined as the ratio of the number of patients
with a negative test result who do not have disease
divided by the total number of tested patients without
the disease
(V Gopikrishna et al, International Journal of Paediatric Dentistry
2009; 19: 3–15)

139. Pulp sensitivity test
• Sensitivity denotes the ability of a test to detect
disease in patients who actually have the disease.
• Indicates the test’s ability to identify non-vital teeth.
• It is defined as the ratio of the number of persons with
a positive test result who have the disease divided by
the total number of persons with the disease who
were tested
• IDEAL method 1.0

140. PULP SENSIBILITY TEST
• Assess by neural sensitivity test - more accurate is to
assess the vascularity of pulp
Neural sensibility tests:- indirectly tell about the
vitality status of pulp – work on the principle of
stimulating nerve fibers
Thermal tests
Electric pulp test
Anesthetic test
Test cavity

141. THERMAL TESTS
• HEAT TEST:
• Materials used :
 Electrical heat carrier
 Hot gutta percha sticks – 78°C
 Hot water under rubber dam isolation
 Hot burnisher
 Hot compound
 Dry rubber polishing wheel

142. • Heat test – when patients complaint – intense pain in
contact with hot liquid
• Helps to identify which tooth is sensitive
• Initially, there is a sharp localized pain reaction due to
stimulation of A-delta fibers, and with continued
stimulation, a dull radiating pain follows due to
activation of the C fibers

143. • Area of test is isolated - dried – lubricant – heat is
directed – patients response
• Solid substance – applied –occluso buccal third of
crown
• No response – move to central portion of crown or
closer to cervical margin
• Tooth isolated – rubber dam – “coffee – hot” water –
in syringe

144. Heat application for ≤5 sec
Vasodilatation
Increased intrapulpal pressure
Reduced neural excitation threshold no response
Immediate excruciating painful POSITIVE RESPONSE similar
Response different from the to contralateral control tooth
contralateral control tooth
OR
Painful response lingers even NON VITAL TOOTH
After removal of stimulus
IRREVERSIBLE PULPITIS HEALTHY STATE OF PULP
(Van Hassels Theory)

145. COLD TEST
• Cold thermal testing causes contraction of the
dentinal fluid within the dentinal tubules, resulting in
a rapid outward flow of fluid within the patent tubules
• This rapid movement of dentinal fluid results in
‘hydrodynamic forces’ acting on the A δ nerve fibres
within the pulp–dentine complex, leading to a sharp
sensation lasting for the duration of the thermal test
(V Gopikrishna et al, International Journal of Paediatric Dentistry 2009; 19:
3–15)

146. COLD TEST
• Endo ice - dichlorodifluoromethane
• CO2 snow
• pencil of ice
• ice cold water
• ethyl chloride
• Green Endo Ice - – 1,1,1,2 tetrafluoroethane

147. • Carbon dioxide snow(Dry ice) –described by
Ehrmann
• Temperature - 78°C
• Principle : passing compressed liquid CO2 through a
small orifice in a holding cylinder onto a Plexiglass
tube to create dry ice “pencil”
• Advantage : – able to penetrate full coverage
restorations
• Disadvantages: cracks in the enamel

148. • Diagnostic accuracy of cold test – 86%
• Electrical pulp test (EPT) – 81%
(combination of cold test and EPT recommended)

149. • CO2 can also be used – solid stick is prepared by
delivering CO2 gas into plastic cylinder
• Stick is placed on the facial surface
• Teeth should be isolated
• Temperature – 78°C

150. • Green Endo ice – 1,1,1,2 tetrafluoroethane –
temperature -26.2°C
• Spray applied on tooth by cotton pellet – placed on
the midfacial area of tooth or crown

151. Cold application for ≤ 15 sec
Positive short sharp excruciating painful NO
Response pain that response that lingers response
disappear on even after removal
removal of stimulus of stimulus
HEALTHY REVERSIBLE IRREVERSIBLE NON
PULP PULPITIS PULPITIS VITAL

152. • Some worry that a piece of dry ice that falls
inadvertently into the mouth could have a deleterious
effect on the mucosa with which it comes into
contact.

153. • But CO2 falls into the mouth it is surrounded by an
insulating layer of gaseous CO2, which does not
harm the mucosa. This is known as ‘film boiling’ or
the ‘Leidenfrost phenomenon’ (Ehrmann 1977)

154. ELECTRIC PULP TEST
• Test pulp vitality
• Use nerve stimulation
• Positive – indicate vitality
• No response – pulp necrosis
• Testers available are monopolar – current flows from the probe
through tooth –through patient back to testing unit
• Past bipolar units – probes placed on either side of tooth
crown- only stimulate vital pulp tissue (difficult to use ,
unavailabe

155. • Isolate the area (cotton rolls and saliva ejector and air
dry all the tooth)
• Test on the control tooth first
• Apply electrolyte (tooth paste)
• Probe tip – anterior – incisal third
• Posterior teeth – mid third of mesiobuccal cusp of
molars and buccal cusp of premolars

156. • Circuit – lip clip in contact with mucosa
• Ask the patient to indicate - tingling or warmth – record the
numeric scale
• Recheck all results – change the sequence of testing

157. • Pulpal response to EPT:
1. Normal response
2. Negative response
3. Early response – denote diseased state of pulp –
tooth respond to threshold less than that of normal
4. Delayed response: diseased state – higher electrical
excitation level
5. False positive :
• Gangrenous necrotic pulp is present

158. • Multirooted teeth – pulp is partially necrotic – some nerve
fibers vital
6. False negative:
• Calcification
• Increased reparative dentin – diminishing pulp cavity
• Fibrotic pulp
• Extensive restoration and pulp protecting base
• Recent trauma - 4–6 weeks following trauma for
sufficient recovery of sensation to obtain valid pulp
testing results

159. • Recently erupted – incomplete root formation – since
these teeth may take upto five years before the
maximum number of myelinated fibres reaches the
pulp-dentine border at the plexus of Rashkow
• Sedative medication
• Patients with high pain threshold
• Orthodontic treatment because the pulp’s sensory
elements may be disturbed for up to nine months.

160. • LIMITATIONS :
• EPT – unreliable in immature permanent teeth, concussed
tooth, full coverage restorations (dry ice)
• Trauma cases – test can be negative for 3 months
• Electrical deficiencies
• Molars may give false readings – vital and non vital canals

161. • Cast crowns – rubber wheel - frictional heat
generated
• Best on the lingual area – not affect the shape of
casting

162. • Sensitivity:
• 0.83 for cold test
• 0.86 – heat test
• 0.72 – EPT
• Specificity:
• 93% - cold and EPT
• 41% - heat test
ACCURACY:
COLD TEST – 86%
EPT – 81%
HEAT TEST – 71%

163. TEST CAVITY
• Performed when other diagnostic methods have
failed.
• Test cavity is made by drilling through enamel dentin
junction of unanaesthetised tooth.
• Sensitivity or pain felt is an indication of pulp vitality
• No response – endodontic access cavity continued

164. ANESTHETIC TEST
• Performed when usual tests have failed to enable one
to identify the tooth.
• Objective is to anaesthetize a single tooth at a time
until the pain disappears and is localized to specific
tooth

165. PULP VASCULARITY TESTS
• True vitality - assessed by vascularity or blood
supply to tooth
 Pulse oximetry
 Laser doppler flowmetry
 Dual wave length spectrophotometry
 Thermography
 Crown surface temperature
 Transmitted light photoplethysmography

166. Pulse Oximetry
• 1974 - a Japanese bioengineer -Takuo Aoyagi, tried to develop
– pulse oximeter
• Nihon Kohden introduced the world’s first ear oximeter
• Susumu Nakajima, a surgeon and an associate of Aoyagi - first
tested the device in patients - reporting it in 1975
• Oximetry refers to determination of percentage of oxygen
saturation of circulating arterial blood – using finger, foot or
ear probes

167. • The oximeter applies a principle known as the Beer-
Lambert law, which states that an unknown
concentration of solute (hemoglobin) dissolved in a
known solvent (blood) can be assessed by the light
absorption of the solute

168. • Probe sensor consists of two light emitting diodes,
one to transmit red light (660 mm) and other to
transmit infra red light (940 mm) and photo detector
on opposite side of vascular bed.
• Oxygenated Hb and deoxygenated Hb absorb
different amounts of light

169. . (A) LED emitting red light at 660 nm. (B) LED emitting infrared light at 940 nm. (C)
Photodetector. (D) Pulse oximeter monitor. (E) Pulse oximeter sensor. (F) Custom-
made pulse oximeter sensor holder. SpO2, oxygen saturation of arterial blood

170. • Change in blood volume – change in the light
absorbed by vascular bed – reach the photodetector –
analyzed by pulse oximeter – determine blood
saturation
• Pulse oximeter monitor – digital display of values –
connected to pulp oximeter sensor

171. • Indications:
• Detect pulpal vitality and blood oxygen saturation
• Traumatized teeth in which temporary paresthesia of
nerves reduces the effectiveness and reliability of the
sensibility testing methods
• Pulse oximetry can be valuable to endodontists who
want to use sedation techniques or frequently treat
medically compromised patients.

172. • Limitations:
• Intrinsic limitations include excessive carbon dioxide
in the blood stream interfering with deoxygenating
values.
• Increased acidity and a metabolic rate arising from
inflammation cause deoxygenating of hemoglobin
and changes in the blood oxygen saturation

173. • Extensively restored teeth
• Subject and the probe should remain very still for
obtaining a reasonable recording.
• Patient variables - low peripheral perfusion, increased
venous pulsations, hemoglobin disorders,
vasoconstriction, hypotension, and body movements
will contribute to false or delayed readings

174. Variations in probe design
• Noblett et al, used a rubber
dam clamp as the base for
the sensor design.
• Two slots were prepared in
each wing parallel to the
tooth surface. Electrical
terminals in slots.
• The slot-type terminal was
selected to allow placement
and removal of the sensor
elements and to maintain a
stable position.

175. (Pulse Oximetry: Review of a Potential Aid in Endodontic Diagnosis Hamid
Jafarzadeh and Paul A. Rosenberg, JOE,2009)
• Gopikrishna et al,
showed that usage of
their custom-made
probe and sensor holder
can be effective and
accurate for determining
pulp vitality

176. Laser Doppler Flowmetry(LDF)
• The Doppler effect is the basis of LDF. The effect
was first described in 1842 by Austrian physicist
Christian Doppler
• First described in dental literature in 1986 by
Gazelius et al.
• Laser Doppler flowmetry is an optical measuring
method that enables the number and velocity of
particles conveyed by a fluid flow to be measured.

177. • LDF was introduced as a non-invasive method to measure the
blood flow.
• Laser light transmitted through fiberoptic source – placed on
tooth surface
• Light enters tooth – absorbed by RBC – lead to a shift in
frequency of scattered light - Doppler principle
• Detected by photodetector
• Used to assess blood movement in pulp space

178. • Two equal-intensity beams
(split from a single beam)
intersect across the target
area.
• The scattered light beams
from moving red blood cells
will be frequency-shifted
whilst those from the static
tissue remain unshifted in
frequency

179. • The reflected light, composed of Doppler-shifted and
unshifted light - is returned by an afferent fibre within
the same probe to photodetectors in the flowmeter
and a signal is produced
• Convert the interference pattern -semiquantitative
measurement -Flux signal- which is measured in
arbitrary units.

180. • Output - Flux is the number of moving red blood cells
per second times their mean velocities
• Flux signal from a tooth with a vital pulp should be
greater than from a tooth with a nonvital pulp

181. • Indications:
• Estimation of the pulpal vitality
• Pulp testing in children
• Periapical radiolucencies may have nonendodontic
origins
• Monitoring of reactions to local and systemic
pharmacological agents
• Monitoring of revascularization of replanted teeth

182. • Limitations:
• Technique sensitive – requires splints to hold the
sensors
• Expensive
• Heavily restored teeth and teeth with vital apical pulp
tissue contraindicated - LDF probes detect only
coronal Pulpal blood flow
• Obstruction in the pathway – restorations, crowns
(Laser Doppler flowmetry in endodontics: a review :H. Jafarzadeh , IEJ 2009)

183. Dual wavelength spectrophotometry
• Method that has previously been considered as a
diagnostic tool to determine pulp status
• Chance et al, developed this technique -measures the
oxygenation change of the blood in the capillary bed
rather than in the supply vessels.
• Technique is not dependent on the pulse of the
vessels, it might be more applicable to the study of
tooth pulp blood flow than pulse oximetry.

184. • Nissan et al, studies suggested that continuous-wave
spectrophotometry may be a better method for testing
pulp vitality.
(Nissan R, Trope M, Zhang CD, et al. Dual wavelength spectrophotometry
as a diagnostic test of the pulp chamber contents. Oral Surg Oral Med Oral
Pathol 1992)

185. Transmitted Laser Light (TLL)
• Is an experimental variation to LDF, aimed at
eliminating the non-pulp signals.
• TLL uses similar sending/receiving probes as
conventional LDF, but the probes are separate.
• Thus the laser beam is passed through from the labial
or buccal side of the tooth to the receiver probe which
is situated on the palatal or lingual side of the tooth.

186. • Limitations - obstruction from within the tooth
structure will affect the results.

187. Photoplethysmography
• It is an analysis of the optical property of a selected
tissue. It was developed for pulp testing in an attempt
to improve pulse oximetry, by adding a light with a
shorter wave length.
• Not fully developed for checking pulp vitality

188. Liquid crystal testing
• “Liquid crystals” was the name that Renitzer gave to
a group of crystal- line cholesteric esters in 1888.
• Noted that when these crystalline cholesteric esters
were heated to their melting points - became liquid
and flowed as expected - but the liquid remained
cloudy and did not become clear until heated to a
much higher temperature.

189. • In 1890 Lehmann, showed that during this cloudy
phase, even though the material was a liquid, it
exhibited crystal like properties under polarized light.
• 1922 - Friedell proposed that, while in this phase,
these cholesteric substances were neither crystals nor
a liquid but in a new state that he called a
“mesophase”.

190. • Ferguson, first reported, in 1964, that liquid crystals
exhibited various colors when heated through their
mesophases and became colorless when heated
beyond the mesophase

191. • This method is based on the assumption that if the
pulp of a tooth becomes nonvital, the tooth no longer
has an internal blood supply and thus should exhibit a
lower surface temperature than that of its vital tooth.
• Method :
• Teeth isolated using rubber dam – thin black strip
coated with cholestric crystals of 300 C - 400 C is
applied and color change is noted using – thermistor
and thermocouple

192. • Color change:
• Vital : blue green , green-blue, red-green, green
• Non vital : green, red, yellow, yellow – red
(The determination of pulp vitality by thermographic means using cholesteric
liquid crystals . Robert M. Howell, Roland C. Duel & Thomas P. Mullaney,
Oral Surg. May, 1970)

193. Hughes Probeye Camera
• It can detect temperature changes as small as 0.10C.
• 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.
• Technique: teeth in question are isolated with rubber
dam and cooled with stream of cold air.

194. (CONTEMPORARY DIAGNOSTIC AIDS IN
ENDODONTICS Divya Jindal, Deepak Raisingani,
Medhavi Sharma, Dileep Soni, Hanisha
Dabas,JEMDS,2014 )
• Symmetrical cooling of
teeth of about 220C is
done. Then teeth are
rewarmed to their former
temperature.
• Vital teeth will rewarm in
5 sec
• non-vital teeth take up 15
sec to rewarm.
• More rapid warming of
vital teeth is due to an
intact blood supply.

195. Xenon 133
• Method of demonstrating blood circulation in the
pulp - by the introduction of a radioactive isotope into
the bloodstream that could be picked up by means of
a radiation probe placed on the crown of the tooth
• Xenon133 is a readily diffusable gas which can be
dissolved in saline.

197. • Study by Trope et al, xenon133 in saline injected into
the periodontium would enter the blood circulation of
the pulp and be picked up by means of a radiation
probe placed in contact with the crown of the tooth
• It was possible to differentiate between vital (higher
counts) and pulpless teeth
• Can only be used by specially licensed individuals in
an institutional setting.
(Vitality testing of teeth with a radiation probe using xenon133 radioisotope.
Trope M, Jaggi J, Barnett F, Tronstad L. Endod Dent Traumatol 1986)

198. Fiberoptic fluorescent spectrometry
• Teeth with vital pulps fluoresced normally but the teeth
with necrotic or absent pulps did not fluoresce when
exposed to ultraviolet light.
• Fluorescence from the pulp was found to be substantially
lower than the healthy and decayed dentin fluorescence.
• Healthy and decayed dentin patterns were different
(Tyagi, et al.New vistas in endodontic diagnosis. Saudi Endodontic Journal
2012)

199. RADIOGRAPHY
• Intraoral periapical radiograph:
• Radiographs should be of good quality
• Radiographs may show the number, course, shape,
length, and width of root canals, the presence of
calcified material in the pulp chamber or root canal,
the resorption of dentin…

200. • Radiograph cannot be reliably used to differentiate a
chronic abscess, a granuloma, or a cyst. To be
accurate - requires histopathological evidence.
• Bender confirmed that loss of cancellous bone is
undetectable until atleast 6.6% of the mineral content
of cortical bone is lost “ Periradicular lesion
is usually larger than its image on a radiograph”

201. • LIMITATIONS:
• Periapical radiographs may not always be accurate in
assessing the spatial relationship between the root and
their surrounding anatomical structures
• Multiple exposures may be necessary

202. • Superimposition of the anatomical features is referred
to as anatomical, structured or background noise -
complicate radiographic interpretation
• To assess the outcome of endodontic treatment,
radiographs exposed over a time period should be
compared -serial radiographs will still show small
inconsistencies

203. • PERIAPICAL INFLAMMATORY LESIONS:
• Early lesions – no radiographic changes
• Location:
• Epicenter of lesion is found at the apex of tooth
• Periphery :
• Usually ill defined
• Internal structure:
• Earliest change – widening of PDL space

204. • Lesion – increased bone formation – periapical
sclerosing osteitis
• Bone resorption - periapical rarefying osteitis
• Effect on surrounding structures :
• Can cause resorption
• Destroy nearby cortical boundaries

205. • Radicular cyst:
• Well defined cortical border , internal structure is
radiolucent , if large – displacement and resorption of
the roots of adjacent teeth

206. • Differentiation from apical granuloma is difficult –
round shape, well defined cortical border and a size
greater than 2cm in diameter are more characteristic
of a cyst

207. • INTERNAL RESORPTION:
• Within the pulp chamber or canal
• Enlargement of the pulp space
• Lesion in pulp chamber of crown – radiolucent area
envelope crown
• Pulp perforates dentin and enamel – pink spot
• In root – clinically silent
• Can weaken the tooth - fracture

208. • Radiograph:
• Localized, radiolucent , round / oval, elongated
within the root or crown and continuous with the
image of root canal
• Irregular widening of pulp chamber or canal
• Homogeneously radiolucent

210. • EXTERNAL RESORPTION:
• Common – apical and cervical regions
• Blunting of root apex - bone and lamina dura follow
resorbing root
• Lateral aspect – lesion irregular – common cause –
unerupted adjacent tooth

212. • PULP STONES:
• Foci of calcification in the dental pulp
• Vary in size – filling the pulp chamber
• Radiopaque structures within pulp chamber or root
canals – round or oval

214. • Hypercementosis:
• Excessive deposition of cementum – tooth roots
• Outline smooth – bulbous enlargement of root
• More evident in the apical end

215. (Oral radiology –Stuart C White and Michael J Pharoah)

216. • Vertical root fractures :
• A vertical root fracture is a longitudinally oriented
fracture of the root that originates from the apex and
propagates to the coronal part.

217. • diffuse widening of periodontal ligament,
dislodgement of retro-filling material, vertical bone
loss , separation of root fragments or displacement of
apical portions of root.
• Presence of ‘radiographic halo’ has been shown as a
major finding in cases of vertical root fractures.
• Radio-lucent halos- at the
apical region giving rise to a
J-shaped radiolucency

218. • A periapical radiograph can detect a fracture line only
in 35.7% cases.
• Superimpositions of root canals on fracture line
• X-ray beam not parallel to the plane of fracture
• Fracture line present in the fused root superimposed
by radiopaque anatomic structures
• Location of fracture line precludes the use
radiograph.
• (Khasnis et al , JCD,2014)

219. Digital radiography
• Can capture, view, magnify, enhance and store
images
• Sensor is used – to capture image
• Better resolution
• 50 – 90% less radiation
• 2 major technologies used are :
• Complimentary metal oxide semi conductor
(CMOS)- silicon based semi conductor

220. • Solid state detectors – charge coupled device (CCD):
• Thin wafer silicon - silicon crystals are formed -
pixel
• Photostimulable phosphor (PSP):
• PSP absorb and store energy from X rays and then
release this energy as light –phophorescence – when
stimulated by another light

221. • Advantages :
• Reduced time
• Reduced radiation dose
• Multiple exposures from different angles
• Elimination of chemical processing
• Images can be duplicated

222. • Images can be stored and retrieved
• Images can be transmitted electronically
• Have measurement tools
• Disadvantages:
• High cost
• Cannot be autoclaved
• Thicker and rigid detectors

223. ADVANCED IMAGING
TECHNIQUES

224. Cone Beam Computerized Tomography(CBCT)
• Computed tomography (CT) is an imaging technique
which produces 3D images of an object by using a set
of 2D image data
• High resolution helps in identifying variety of cysts,
cancerous lesions, infections, developmental
discrepancies and traumatic injuries involving the
maxillo-facial structures.

226. • Eliminates anatomical noise and high contrast resolution,
allows differentiation of tissues with less than 1% physical
density difference to be distinguished in comparison to
conventional radiography that requires 10%
• Viewed as images in the coronal, sagittal or cross-sectional
planes from the axial slices depending on the diagnostic task
• Determination of the number of roots and root canals

227. • LIMITATIONS:
• High radiation dose and the high costs of the scans
( Nivesh et al, Recent Diagnostic Aids in Endodontics- A Review
IJPCR, August 2016 )

228. Tuned Aperture Computed Tomography (TACT)
• Developed by Webber and colleagues
• It creates 3D information from a series of 8-10
periapical radiographic images exposed at different
projection geometries, using a programmable imaging
unit with specialized software
• Helps in detection of extra canals and root fractures
• less anatomical noise in the area of interest

229. • Radiation is not higher than 1 to 2 times that of a conventional
periapical X-ray film.
• Limitation :
• Trial stage in dental applications
( Nivesh et al, Recent Diagnostic Aids in Endodontics- A Review IJPCR,
August 2016 )

230. Magnetic Resonance Imaging (MRI)
• MRI is a completely noninvasive specialized imaging
technique which uses radio waves instead of ionizing
radiation.
• It involves the behaviour of hydrogen atoms
(consisting of one proton and one electron) within a
magnetic field
• Investigation of soft tissue lesions especially in
salivary glands, investigation of the
temporomandibular joint and tumour staging

231. • Used for the investigation of pulpal and periapical
condition
• LIMITATIONS:
• poor resolution compared with conventional
radiographs and longer scanning times
• restricts its use in patients carrying a pacemaker
• Cannot differentiate hard tissues

232. ULTRASOUND
• Due to it’s high resolution, 3-D images of the
innermost structure of the tooth can be viewed
• Based on the phenomenon of reflection of ultra sound
waves (echoes) at interfaces between tissues that have
different acoustic properties.
• Ultrasound beam of energy is emitted and reflected
back to the same probe reflected back waves
produce echo

233. • Hypoechoic or transonic – low echo intensity
• Anechoic – no reflection of echoes occurs in any area filled
with fluid.
• Hyperechoic – high echo intensity (bone and teeth – white)
• The Doppler effect, which is the change of frequency of sound
reflected from a moving source, can be used to detect the
arterial and venous blood flow

234. • Cystic lesions - hypo echoic, well contoured cavity,
surrounded by reinforced bone walls, filled with fluids, no
evidence of internal vascularization on Color Power Doppler
examination
• Granuloma : Poorly defined lesion, could be hyper echoic or
both hypo & hyper echoic, exhibiting rich vascular supply on
color Doppler examination

235. • Limitations:
• Sound waves are blocked by bone, Ultra Sound (US) is
useful only for assessing the extent of periapical lesions
where there is little or no overlying cortical bone
• Interpretation of US images is usually limited to
radiologists who have extensive training
(Cotti et al, Ultrasound real time imaging in the differential diagnosis of
peripical leions, IEJ 2003)

236. PULPAL DIAGNOSIS
• Normal Pulp -pulp is symptom-free and normally
responsive to pulp testing..
• “clinically” normal pulp results in a mild or transient
response to thermal cold testing, lasting no more than
one to two seconds after the stimulus is removed.

237. • Reversible Pulpitis - inflammation should resolve
and the pulp return to normal following appropriate
management of the etiology.
• Discomfort is experienced when a stimulus such as
cold or sweet is applied and goes away within a
couple of seconds following the removal of the
stimulus.

238. • Etiologies may include exposed dentin (dentinal
sensitivity), caries or deep restorations. There are no
significant radiographic changes in the periapical
region of the suspect tooth and the pain experienced
is not spontaneous.

239. • Symptomatic Irreversible Pulpitis
• Characteristics may include sharp pain upon thermal
stimulus, lingering pain (often 30 seconds or longer
after stimulus removal), spontaneity (unprovoked
pain) and referred pain.
• Sometimes the pain may be accentuated by
postural changes such as lying down or bending
over and over-the-counter analgesics are typically
ineffective.

240. • Common etiologies may include deep caries,
extensive restorations, or fractures exposing the
pulpal tissues.

241. • Asymptomatic Irreversible Pulpitis
• These cases have no clinical symptoms and usually
respond normally to thermal testing but may have had
trauma or deep caries that would likely result in
exposure following removal.

242. • Pulp Necrosis
• The pulp is non-responsive to pulp testing and is
asymptomatic.
• Pulp necrosis by itself does not cause apical
periodontitis (pain to percussion or radiographic
evidence of osseous breakdown) unless the canal is
infected.
• Some teeth may be nonresponsive to pulp testing
because of calcification, recent history of trauma...

243. • Previously Treated is a clinical diagnostic category
indicating that the tooth has been endodontically
treated and the canals are obturated with various
filling materials other than intracanal medicaments.
The tooth typically does not respond to thermal or
electric pulp testing.

244. • Previously Initiated Therapy is a clinical diagnostic
category indicating that the tooth has been previously
treated by partial endodontic therapy such as
pulpotomy or pulpectomy. Depending on the level of
therapy, the tooth may or may not respond to pulp
testing modalities.

245. • Symptomatic Apical Periodontitis represents
inflammation, usually of the apical periodontium,
producing clinical symptoms involving a painful response
to biting and/or percussion or palpation.
• This may or may not be accompanied by radiographic
changes.
• Asymptomatic Apical Periodontitis is inflammation and
destruction of the apical periodontium that is of pulpal
origin. It appears as an apical radiolucency and does not
present clinical symptoms

246. • Chronic Apical Abscess is an inflammatory reaction
to pulpal infection and necrosis characterized by
gradual onset, little or no discomfort and an
intermittent discharge of pus through an associated
sinus tract.
• Radiographically, there are typically signs of osseous
destruction such as a radiolucency.

247. • To identify the source of a draining sinus tract when
present, a guttapercha cone is carefully placed
through the stoma or opening until it stops and a
radiograph is taken.

248. • Acute Apical Abscess is an inflammatory reaction to
pulpal infection and necrosis characterized by rapid
onset, spontaneous pain, extreme tenderness of the
tooth to pressure, pus formation and swelling of
associated tissues.
• There may be no radiographic signs of destruction
and the patient often experiences malaise, fever and
lymphadenopathy

249. • Condensing Osteitis is a diffuse radiopaque lesion
representing a localized bony reaction to a low-grade
inflammatory stimulus usually seen at the apex of the
tooth.
(AAE GUIDELINES)

250. CONCLUSION
• Proper diagnosis and treatment planning play a
critical role in the quality of dental care.
• Examination, diagnosis, and treatment planning are
extremely challenging and rewarding for both the
patient and the dentist if done thoroughly and
properly with the patients best interest in mind.

251. REFERENCES
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2. Grossmans ENDODONTIC PRACTICE – 13th edition
3. Cohens Pathways of the PULP – 10th edition
4. ENDODONTIC THERAPY -6th edition – Franklin S Weine
5. ENDODONTICS Principles and Practice – 4th edition – Mahmoud
Torabinejad, Richard E Walton
6. Eugene Chenand and Paul V Abbott. Dental Pulp Testing: A
Review; International Journal of Dentistry 2009
7. AAE Quick Reference Guide on Antibiotic Prophylaxis 2017
Update
8. P Carrotte. BRITISH DENTAL JOURNAL VOLUME 197 NO. 5
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252. 9. Divya Jindal, Deepak Raisingani, Medhavi Sharma, Dileep Soni, Hanisha
Dabas. “Contemporary Diagnostic AIDS in Endodontics”. Journal of
Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue 06,
February 10; Page: 1526-1535
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vitality: a review; International Journal of Paediatric Dentistry 2009; 19:
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253. 14. Nivesh Krishna R, Pradeep S. Recent Diagnostic Aids in Endodontics- A
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