An overview of the diagnostic process in endodontics, including information about the pain system, referred pain, non-odontogenic pain, the diagnostic process, tests and treatment planning in endodontics.

1. DIAGNOSIS IN
ENDODONTICS
Fatima A. A.

2. Diagnosis



“The science of recognizing disease by means of signs,
symptoms and tests.”
Effective treatments depends on an accurate diagnosis
Two broad diagnostic scenarios:
 Emergency
 As
part of a comprehensive treatment

3. Diagnostic Process
Chief
Complaint
History:
Medical &
Dental
Examination:
Extra-oral &
Oral
Data
Analysis
Differential
Diagnosis
Treatment

4. Diagnostic Possibilities

Pulpal Diagnosis
Normal
 Reversible Pulpitis
 Irreversible Pulpitis
 Necrosis


Periapical Diagnosis
Normal
 Acute Apical Periodontitis
 Chronic Apical Periodontitis
 Acute Apical Abscess
 Chronic Apical Abscess
 Condensing Osteitis


5. Chief Complaint
The first information obtained

6. Importance


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

Volunteered by the patient
In patient’s own words
Patient will judge the outcome of the treatment
according to how well it resolved the chief complaint
Opportunity to capture patient’s confidence
Capturing patient’s confidence facilitates education of
the patient regarding diagnosis and treatment
approach

7. Common Presenting Complaints

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Pain
Swelling
Broken tooth
Loose tooth
Tooth discoloration
Bad taste

8. Pain



“An unpleasant sensory and emotional experience
associated with actual or potential tissue damage.”
Most important and obvious complaint
Types of Pain:
Acute: Protective, arising from inflammation or injury to pulp
and periapex
 Chronic: Non-protective, persists after or unrelated to injury


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Pain experience may be modulated by affective,
motivational and cultural factors
Peripheral and central changes after inflammation or
injury may contribute to the development of hyperalgesia
(increased response to painful stimulus), allodynia (pain
provoked by normally non-painful stimulus), and
spontaneous pain (unrelated to stimulus)

9. Pain System

The “pain system” consists of:
 Nociceptors
 Small
 A

C
diameter nerve fibers
fibers
Fast-conducting, sharp pain
fibers

 A

Slow-conducting, dull throbbing pain
fibers
Not normally nociceptive but may be recruited due to central
sensitization
 Tracts
 Central

processing areas
During pulpal inflammation, C fibers dominate

10. Central Sensitization



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Prolonged nociceptive input leads to functional changes in
the subnucleus caudalis, the spinal dorsal horn, and the
thalmus
A major change is up-regulation of NMDA receptors on
second-order neurons
These changes produce hyperalgesia and widen the
receptive fields
Recruitment of normally non-pain fibers can produce
allodynia
Spontaneous activity occurs
Widening of receptive fields and up-regulation of NMDA
receptors enables convergence of input from multiple
areas, leading to the referred pain phenomenon

11. Pain Referral Phenomenon



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Pain from one site is felt at another
Convergence of neurons from other sites on a sensitized
second-order neuron leads non-nociceptive levels of activity
from these sites being misidentified as pain by higher centers
of the pain system
Referred pain never crosses the midline
Common sites where pain may be referred from:


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Other teeth
Muscles of mastication
Sinuses/respiratory system
Cardiac muscle
Anesthetizing the true site of origin eliminates pain in referred
sites
Referred pain is a common occurrence

12. Endodontic Pain

True origin is often silent

May be referred, including to site of recent dental treatment

Tooth pain may not be related to pulp condition

Often poorly localized

Periodontal pain is more easily located than pulpal pain

Difficult to anesthetize inflamed pulp

Patients have often used analgesics

There may be multiple pain sources

Different pain presentations may require different treatment strategies

Stress and insomnia are often related to bruxism and
temporomandibular disorder pain which can be referred to the pulp,
complicating treatment with an amalgamation of psychogenic and
organic factors

13. Non-Odontogenic Pain
Origin
Muscular
Joint
(Common) Underlying
Disorder/Disease
Myospasm
Myositis
Fibromyalgia
Myofascial Pain Syndrome
Temporomandibular Disorders
Characteristics
• Deep
• Dull, aching
• May be felt extra-orally near the ear,
temple or on the face
• Muscles of mastication most
commonly affected
• Depending on the location of the
trigger point, the pain may progress
from maxillary anteriors to premolars
and then to maxillary molars
 Dull
 ‘Drilling’ ache
 Worsened by chewing or opening
mouth
 Limited mouth opening
 Clicking sound
 Tenderness anterior to tragus of ear
 Deviation upon opening or dislocation
of the jaws

14. Origin
Neurologic
Vascular
(Common) Underlying
Disorder/Disease
Characteristics
Trigeminal neuralgia
Glossopharyngeal Neuralgia
Post-herpetic neuralgia
 Trigeminal neuralgia: deep,
lancinating, electrical paroxysmal
pain classically lasting less than 2 min,
triggered by light touch or chewing,
following the course of the branches of
fifth cranial nerve.
 Glossopharyngeal neuralgia: severe,
jabbing pain in the pharynx and oral
cavity parts supplied by ninth cranial
nerve (tongue, throat, tonsils), triggered
by chewing or swallowing.
 Post-herpetic neuralgia: burning or
stabbing pain following an attack of
herpes zoster.
Migraine
Giant Cell Arteritis
Cluster headaches
Neuralgia-inducing
Cavitational Necrosis
(neurovascular)
 Throbbing, burning pain
 Cluster headaches: pain may be deep,
sudden, electric shock-like
 Pain follows the course of its vascular
origin

15. Origin
Inflammatory
Neoplasms
(Common) Underlying
Disorder/Disease
Characteristics
Sinusitis
Parotitis
Otitis media
 Sinusitis: referral pain in maxillary
teeth, facial pain, swelling and
tenderness in the maxilla
 Parotitis: stringent, drawing pain
 Otitis media: pain may be referred to
teeth and jaws.
Osteosarcoma
Chondrosarcoma
Ewing’s Sarcoma
 Tumors are rarely painful. Most
patients present with tooth mobility or
other symptoms.
Angina pectoris
Manifestation of Systemic Myocardial Infarction
Atypical odontalgia
Disease/disorder
(Psychogenic)
 Cardiogenic pain is typically
described as a pressure or burning
sensation, and may be left-sided
and/or associated with chest pain.
 Psychogenic pain will persist despite
absence of pathology, may be
unresponsive to treatment, and are
often associated with other psychiatric
conditions such as anxiety disorders or
somatization disorders.

16. Health History
Clinical records to be reviewed during every visit

17. Preliminary Concerns



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Endodontic patients are generally older than average
This population shows a higher and more complex
incidence systemic medical problems
Reduced response to treatment
Treatment complicated by other factors such as
bisphosphonate therapy

18. Antibiotic Prophylaxis

Indications:

Cardiac patients:

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Artificial heart valves
History of infective endocarditis
Congenital heart tissue defects and repairs
Heart transplants
Immunocompromised patients
Hemophiliacs
Insulin-dependent diabetics
Patients who have had a joint replacement in the past 2 years
Regimen


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Adults: 2 g amoxicillin 30-60 min pre-op
Children: 50 mg/kg
Penicillin-sensitive patients: clindamycin 600 mg 30-60 min pre-op

19. Dental History

History of the Presenting Complaint:
 Onset
 Severity
 Duration
 Frequency
 Variation
 Aggravating
factors
 Relieving factors

Previous dental treatment (related and/or unrelated
to presenting complaint)

20. Questions about Pain

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When did the pain begin?
Where is he pain located?
Is the pain always in the same place?
Hat is the character of the pain?
Does the pain prevent working or sleeping?
Is the pain worse in the morning or evening?
Is the pain worse when you lie down
Did or does anything initiate the pain?
Once initiated how long does the pain last
Is the pain continuous, spontaneous or intermittent
Does any thing make the pain worse
Does anything make the pain better?

21. Questions about Swelling
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When did the swelling begin?
How quickly has the selling increased in size
Where is the swelling located
What is the nature of the swelling
Is there drainage from the swelling
Is the swelling associated with the loose or tender
tooth

22. Examination
Collecting clinical evidence of pathology

23. Extra-Oral Examination
•
General appearance
•
Swelling
•
Scars
•
Skin tone
•
Discoloration
•
Sinus tracts
•
Facial asymmetry
•
Redness
•
Lymphadenopathy

24. Intra-oral Examination
•
Soft-tissue discoloration
•
Parulis
•
Tooth erosion
•
Inflammation
•
Intraoral swelling
•
Caries
•
Ulceration
•
Tooth fractures
•
Failing restorations
•
Sinus tracts
•
Tooth abrasion
•
Tooth discoloration

25. Diagnostic Aids
Tests and Radiographs

26. Control Teeth
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Prior to performing any test, the clinician should
select “control teeth”
This calibrates the test and provides a baseline with
which to compare the patient's response
Control teeth should be similar to the suspect tooth
As referred pain cannot cross the midlline, it may be
preferable to select control teeth on the
contralateral side
The first application of the test is most significant

27. Percussion
•
•
How: Use gentle digital pressure to detect exceptionally tender teeth that should NOT
be percussed, then tap the occlusal or incisal surface of suitable with a mirror handle
held parallel or perpendicular to the crown
Result: Sharp pain indicates periapical inflammation; mild-to-moderate pain or pain
restricted to tapping of facial surface is likely to be due to periodontal inflammation

28. Palpation
•
How: Apply firm pressure on the mucosa overlying the apex of the suspect tooth
•
Result: Pain indicates periapical inflammation

29. Cold Stimulation
•
•
How: Dry and isolate the tooth, then apply an ice stick or large cotton pellet soaked
with refrigerant
Result: Intense, prolonged response indicates irreversible pulpitis; lack of response
indicates necrotic pulp. False negative may occur in case of teeth with calcified canals
(eg aged dentition) whereas false positive may occur if cold sensation is transferred to
vital teeth or gingiva

30. Heat Stimulation
•
•
How: It is best and safest to use a dry rubber prophy cup to produce frictional
heat, after isolating the tooth with a rubber dam; alternatively, a syringe filled
with hot water may be used
Result: A sharp non-lingering response indicates vital (not necessarily normal) pulp

31. Electric Stimulation
•
•
How: Clean, dry and isolate the tooth before applying a small amount of
conducting medium/toothpaste on the electrode and placing it on the tooth; a lip
clip or asking the patient to hold the metal handle completes the circuit
Result: Absence of a response indicates necrosis; false negative may occur in
case of calcified canals—margin of error is 10%-20%

32. Blood Flow Determination
•
•
How: Sensors (dual wavelength spectrophotometer, pulse oximeter, or laser
Doppler flowmeter) are applied to the facial and lingual surfaces to detect
oxyhemoglobin levels in blood or pulsations in the pulp
Result: Adequate perfusion indicates vital pulp with good healing potential

33. Dentin Stimulation
•
•
How: When other tests are inconclusive, a small test cavity is made using a sharp
bur without anesthesia
Result: Sudden sensation of pain upon reaching dentin indicates vital pulp

34. Periodontal Examination
•
•
How: Probing with a periodontal probe, followed by mobility testing using the
index finger on the lingual surface while pressure is applied via a mirror handle
on the facial surface
Result: Periodontal health differentiates between periapical and periodontal
lesions, and also acts as a prognostic indicator for root canal therapy

35. Radiographs
•
•
How: Radiographs may be 2D or 3D and digital or traditional film-based; they
all involve passing radiation through tissue
Result: Apical loss of lamina dura, apical lucency that resembles a “hanging
drop” and persists despite different cone angles, necrotic pulp, and radiopaque
changes such as condensing osteitis indicate periapical lesion of endodontic origin

36. Additional Diagnostic Tests

Caries removal
 Complete
removal of soft caries (using a hand instrument)
leading to exposure of pulp indicates irreversible pulpitis

Selective anesthesia
 If
a patient has difficulty localizing a painful tooth,
mandibular block will confirm the region in case of
mandible; a PDL injection delivered in an anterior to
posterior sequence is more effective in the maxilla

Transillumination
 Contrasting
vertical and dark segments of the tooth are
produced because fracture sites do not transmit light; teeth
with longitudinal coronal fractures are also often tender to
biting

37. Data Analysis & Differential Diagnosis
“When you have eliminated the impossible,
whatever remains, however improbable, must
be the truth.” –Sherlock Holmes

38. Reaching a Diagnosis
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The diagnostic process should be followed in sequence
to ensure systematic collection of data
All data should be recorded and reviewed to give the
clinician a detail-rich “whole picture”
In most cases, the clinician should be able to list a
number of differential diagnoses in order of likelihood
Specific confirmatory tests may be undertaken to
eliminate diagnoses from this list and arrive at a
conclusive diagnosis
In case of a strongly evidenced, highly likely
provisional diagnosis it may be adequate to initiate
treatment

39. Difficult Diagnosis

A diagnosis is likely to be difficult if:
 Patient
is unable to localize pain
 No local identifiable dental cause of pain
 Spontaneous or intermittent pain not necessarily elicited by
a stimulus
 Non-reproducible symptoms
 Suspected tooth shows no clear etiology
 Multiple teeth involved
 Bilateral symptoms
 Selective anesthesia fails to localize pain source

40. Treatment Planning
Last step of the diagnostic process, first step of
the follow-up process

41. Choice of Treatment



Both the course and ultimate success of the treatment
follow the accuracy and comprehensiveness of the
diagnosis
In most cases, once an endodontic diagnosis is
established, treatment is intracoronal (“conventional”
or “non-surgical”)
Surgical treatment is indicated when coronal access to
the canal system is impossible

42. Procedure Difficulty


The difficulty of surgical and non-surgical procedures
should be assessed before undertaking the treatment
If a patient has pain or swelling, emergency care
should be provided even if ultimately the patient is to
be referred to an endodontic specialist

43. Scheduling

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Single and multiple appointment therapies have the same
success rate and same rate of post-therapy complication
Most patients prefer single-appointment therapy
Complex conditions require multiple appointments
Time requirements should be discussed with the patient
beforehand to plan a realistic, feasible schedule
Patients with severe periapical symptoms or persistent
canal exudation should be treated as quickly as possible,
with none or minimal time between appointments to
compensate for increased risk of flare-ups
Flare-ups in such patients are considerably difficult to
manage after canal obturation

44. End

45. References
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“Endodontics: Principles and Practice” by
Mohamoud Torabinejad & Richard E. Walton, 4th
edition
“Differential Diagnosis of Toothache Pain” by Dr.
Lisa Germain
“Differential Diagnosis of Odontalgia” by College
of Diplomates
“A Note on Pulp Vitality Testing in Endodontics” by
Upul Cooray