This scholarly presentation delves into the array of diagnostic aids currently revolutionizing the field of endodontics. From cone-beam computed tomography (CBCT) to advanced pulp vitality tests, the talk evaluates the accuracy, efficacy, and limitations of various diagnostic tools. It will discuss their integration into a coherent diagnostic workflow, supported by the latest research and technological advancements. This presentation is crucial for endodontists, oral radiologists, postgraduate dental students, and researchers interested in leveraging precise diagnostic tools for improved clinical outcomes in endodontic care.

1. Presented by – Dr. Ishaan Adhaulia

2. CONTENTS
• Diagnosis?
• Diagnostic Workflow
• History and Record
• All About Pain
• The Diagnostic Aid Pool
• Conventional Diagnostic Aids
• Neural Sensitivity Tests
• Pulp Vascularity Tests
• Recent Diagnostic Aids
• Conclusion
• References
2

3. What is Diagnosis?
• Diagnosis is the correct determination, discriminative estimation,
and logical appraisal of conditions found during examination as
evidenced by distinctive signs, marks, and symptoms.
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
3

4. Diagnostic Workflow
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
4

5. History and Record
Chief Complaint History of Present Illness Previous Dental History
Medical History Personal Dental History Clinical Examination
Intraoral Examination Investigations Final Diagnosis
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
5

6. Chief Complaint
• Main complaint or concern of the patient
• In patients’ own words
• Patient is encouraged and guided to discuss all
aspects of current problem
History taking and clinical examination in dentistry. Charu M Marya, (2014)
6

7. Maheswaran T, Ramesh V, Krishnan A, Joseph J. Common chief complaints of patients seeking treatment in the government dental institution of Puducherry, India. J Indian Acad Dent Spec Res. 2015 Jul 1;2(2):55-8.

8. History of present illness
• Severity and Urgency of the problem
Site of pain Mode of onset
Duration of pain
Types of pain
Progression of pain
S.O.C.R.A.T.E.S
History taking and clinical examination in dentistry. Charu M Marya, (2014)
Nature of pain
Aggravating Factors Relieving Factors
Radiation of pain

9. Dental History
Frequency of past visits
Previous restorative, periodontic,
endodontic or oral surgical treatments
Reasons for loss of teeth
Fluoride History
Attitude towards previous dental treatment
History taking and clinical examination in dentistry. Charu M Marya, (2014)
Frequency of Dental Prophylaxis

10. Medical History
• Identification of any condition that may complicate or
contraindicate the proposed dental treatment
Communicable Diseases
Allergies from certain drugs
Systemic diseases
History taking and clinical examination in dentistry. Charu M Marya, (2014)
Drug History

11. Personal Dental History
Oral Habits Oral Hygiene Habits
Diet History
Adverse Habits
History taking and clinical examination in dentistry. Charu M Marya, (2014)

12. Clinical Examination
Visual Inspection
Palpation
Auscultation
Olfaction
Percussion
Aspiration
History taking and clinical examination in dentistry. Charu M Marya, (2014)

13. Extra-Oral Examination
Skin
Lips
Face
TMJ
Lymph Nodes
History taking and clinical examination in dentistry. Charu M Marya, (2014)

14. Intra-Oral Examination
History taking and clinical examination in dentistry. Charu M Marya, (2014)
Lips / Labial Mucosa Buccal Mucosa
Tongue Tonsils & Oro-Pharynx Hard Tissue Examination

15. History & Record
Subjective Objective

16. History & Record
Differential Diagnosis
Diagnosis by Exclusion
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
Provisional Diagnosis

17. All About Pain
• An unpleasant or sensory emotional experience associated
with actual or potential tissue damage, or described in terms
of such damage (IASP 2020)
Pulpal pain
KIND LOCATION
DURATION
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

18. All About Pain
KIND LOCATION DURATION
• Sharp, Piercing, Lancinating
(reversible pulpitis)
• Dull, Boring or Gnawing
(irreversible pulpitis)
• Localized Pain
(Reversible Pulpitis)
• Diffused Pain
(Irreversible Pulpitis)
• Short and Specific to stimuli
(Reversible Pulpitis)
• Persistent & Lingering pain
(Irreversible Pulpitis)
• Spontaneous Pain
(Irreversible Pulpitis)
• Nocturnal / Postural Pain
(Irreversible Pulpitis)
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

19. The Diagnostic Aid Pool
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
CONVENTIONAL
1) Visual & Tactile Inspection
2) Percussion
3) Palpation
4) Mobility & Depressibility
5) Bite Test
RADIOGRAPHIC
1) Intraoral periapical radiographs
2) Bitewing Radiographs
3) Digital Radiography
4) Cone Beam Computed Tomography
ASSESSMENT OF PULP VITALITY
NEURAL SENSIBILITY TESTS
1) Thermal Tests
1.1) Heat Testing
1.2) Cold Testing
1) Electric Pulp Test
2) Anesthetic Test
3) Test Cavity
PULP VASCULARITY TESTS
1) Pulse Oximetry
2) LASER Doppler flowmetry
3) Recent Technologies
3.1) Dual Wave Spectrophotometry
3.2) Thermography
3.3) Crown Surface Temperature
3.4) Transmitted Light Photoplethysmography

20. Conventional Methods
 Visual and tactile inspection
 Percussion
 Palpation
 Mobility and Depressibility
 Bite Test
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

21. Visual & Tactile Inspection
• The most simple yet essential diagnostic test
• Casual examination = Loss of information
• Three ‘C’ Inspection : Colour / Contour / Consistency
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

22. Normal Vital Tooth Non-Vital Tooth
Discolouration due to
old amalgam filling
Crack developing on marginal
ridge & extending into the
pulp chamber
HARD TISSUES
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

23. Normal Contour, Colour &
Consistency of Gingiva
Inflamed gingiva losing its
contour, colour &
consistency
Sinus Tract Parulis Detection of origin of sinus
tract
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

24. Tactile Examination
Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)

25. Palpation
• Test done with fingertips
What do we get to know ?
- Whether the tissue is fluctuant & enlarged
enough for incision and drainage
- Presence, intensity and location of pain
- Presence and location of adenopathy
• Palpation tenderness decreases in
mandibular molars
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
Submandibular Lymph Nodes Infected
Submental Lymph Nodes Infected

26. Percussion Testing
Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)
Apical Pathology Periodontal Pathology
Symptomatic of
Standardization of force

27. Percussion Testing
Bruxism
Sensitive to
percussion in one
direction
Periodontitis
Sensitive to
percussion
in any
direction
Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)

28. Bite Pressure Test
• Pt. c/o of having difficulty to chew from one
side of the mouth
• Percussion test is not useful
• Bite test performed on such patients
Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)
“Tooth Slooth” (Professional
Results
Inc., Laguna Niguel, CA, USA)
Wooden Stick

29. Mobility Testing
A result of
The mobility test is used to evaluate the integrity of the attachment apparatus
surrounding the tooth
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

30. Millers Mobility Tooth Index
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

31. Depressibility Testing
Test for depressibility is performed by applying
pressure in the apical direction on the occlusal
or incisal aspect of the tooth and observing
vertical movement if any
Periapical granulomas have a characteristic
positive response to depressibility tests
Endodontic treatment should NOT be
carried out in such teeth
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

32. Radiographic Methods
Intra-Oral Periapical Radiographs
Bitewing Radiographs
Digital Subtraction Radiography
Cone Beam Computed Tomography

33. Intra-Oral Periapical Radiographs
• Intra Oral Peri Apical Radiographs –
Diagnosis of caries since times
immemorial
• It should not be the expectation
that every pulpally involved tooth
will have radiographic signs of
pathosis.
Proximal caries in maxillary
second premolar
Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)

34. Radiographic Applications in Endodontics
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
According to Walton & Gomez :

35. Bitewing Radiographs
White, Stuart C., and Michael A. Pharoah. Oral Radiology: Principles and Interpretation. St. Louis, MO: Elsevier, 2015.
Interproximal Caries Crowns and alveolar crest of maxillary and
mandibular teeth
DIAGNOSTIC OBJECTIVES

36. Digital Subtraction Radiography
• Images of low diagnostic value are reduced
• Changes in radiograph can be precisely detected
• Picture of radiograph taken using high quality video
camera, then fed into a computer called ‘digitizer’
• Two radiographs with identical exposure are used, one
called ‘reference image’, other taken for comparision.
• Both images are superimposed, differences between the
two can be seen as dark areas.

37. Digital Subtraction Radiography

38. Cone Beam Computed Tomography
• Most significant technological advancement in in
maxillofacial imaging
• Acquires data volumetrically providing 3D
radiographic imaging
• Recordings reconstructed in Voxels
White, Stuart C., and Michael A. Pharoah. Oral Radiology: Principles and Interpretation. St. Louis, MO: Elsevier, 2015.

39. Cone Beam Computed Tomography
Assessment of the outcome of the root canal treatment
de Paula-Silva et al evaluated periapical repair after root
canal treatment in using CBCT and Periapical
radiographs Six months after treatment, a favourable
outcome was detected in 79% of teeth assessed with
periapical radiographs in comparison to 35% when CBCT
was used

40. Cone Beam Computed Tomography
Assessment of Dental Trauma and Extent of Lesions
The absence of radiographic signs when the X-ray beam is not parallel to
the plane of the root fracture, tooth displacement and/or alveolar bone
fracture is a limitation of intra-oral Periapical radiographs
Horizontal root fractures usually affect maxillary central incisors and are
typically traumatic in origin, associated with accidents, sports injuries or
fights

41. Cone Beam Computed Tomography

42. Applications in Endodontics
• Extra canals and suspected complex morphology
• Localization of calcified canals
• Detection of vertical root fracture
• Assessment of endodontic treatment
complications
• Presurgical treatment planning
• Localization and differentiation of external and
internal resorptive defects
White, Stuart C., and Michael A. Pharoah. Oral Radiology: Principles and Interpretation. St. Louis, MO: Elsevier, 2015.

43. Neural Sensibility Tests
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

44. Heat Test
Flow of dentinal fluid towards pulp
Salgar AR, Singh SH, Podar RS, Kulkarni GP, Babel SN. Determining predictability and accuracy of thermal and electrical dental pulp tests: An in vivo study. Journal of Conservative Dentistry: JCD. 2017
Jan;20(1):46.
65.5 Celsius
5 seconds
Not as accurate as Cold Test
Gutta Percha Stick / Ball Burnisher /
Prophy Cup without water
Positive
Pressure
C-fibres stimulated

45. Cold Test
Ice Sticks / Ethyl Chloride / DichloroDifluoroMethane / Dry Ice
Positive Pressure
Isolate the tooth
Cotton Pellet to be used Endo Frost (-50*C)
TFE (-26*C)
Salgar AR, Singh SH, Podar RS, Kulkarni GP, Babel SN. Determining predictability and accuracy of thermal and electrical dental pulp tests: An in vivo study. Journal of Conservative Dentistry: JCD. 2017
Jan;20(1):46.
15 seconds

46. Anesthetic Test / PDL Shot
Performed when all other tests have failed
Anesthetizing one tooth at a time until pain is
localized to a specific tooth
If pain cannot be identified as from maxillary or
mandibular origin – nerve blocks are given
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

47. Electric Pulp Test
Uses Nerve Stimulation Unreliable for immature permanent teeth
Uses Nerve Stimulation Normal Negative Positive
Early Delayed False Positive & False Negative
Not done in full coverage restorations
Sui H, Lv Y, Xiao M, Zhou L, Qiao F, Zheng J, Sun C, Fu J, Chen Y, Liu Y, Zhou J. Relationship between the difference in electric pulp test values and the diagnostic type of pulpitis. BMC Oral Health. 2021 Dec;21(1):1-0.

48. Pulp Vascularity Tests
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
Dental Pulse Oximetry
Laser Doppler Flowmetry

49. Dental Pulse Oximetry
Non-invasive method to measure
oxygen saturation levels of blood
Works on the principle of light
absorption by blood and analyzing
the relationship between the
pulsatile changes of absorption
NOT COMMERCIALIZED YET

50. Principle of Dental Pulse Oximetry
POS
POM
Photodetector
Red + Infrared light
Units consists of POS + Photodetector + POM
POS = red light (660nm) + infrared light (940nm)
Oxygenated and De-Oxygenated blood absorbs
different amounts of red & infrared light
Pulsatile change in the blood volume causes
periodic changes in the amount of red and infrared
light absorbed by the vascular bed before reaching
the photodetector
The relationship between the pulsatile change in
the absorption of red light and the pulsatile
change in the absorption of infrared light is
analyzed by the pulse oximeter to determine the
saturation of arterial blood.
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

51. Laser Doppler Flowmetry
Non Invasive Method
Measures rate of blood flow
in a microvasculature
Continuous
Real-Time
Readings largely dependent on the linearity of the
flowmeter output to the changes in the RBC Flux
Red He-Ne gas lasers & Near
Infrared Diode Lasers used
COSTLY
Depth penetration of N.I.R Diode lasers is
more compared to He-Ne Lasers
Obeid AN, Barnett NJ, Dougherty G, Ward G. A critical review of laser Doppler flowmetry. Journal of medical engineering &
technology. 1990 Jan 1;14(5):178-81.

52. Principle of Laser Doppler Flowmetry
Laser light transmitted through
fiberoptic source and placed on
tooth surface
Light enters RBC’s which leads
to shift in frequency of
scattered light
The proportion of frequency
shift is detected by a
photodetector
Detection of blood movement
through pulp space done
Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.

53. Recent Diagnostic Aids in Endodontics
 Computed Infrared Thermographic
Imaging
 Tuned Aperture Computed Tomography
 Fiber-optic Trans-illumination Method
 Thermistor
 Orascope

54. Computed Infrared Thermographic Imaging
Measures the surface
temperature of tooth accurately
Temperature can be measured
from a distance
Accurately indicates
pulpal blood flow
Camera is capable of detecting temperature
changes as small as 0.1 degree Celsius
Non - Invasive
Real Time Data
Saxena AS, Patle B, Lambade P. Advanced diagnostic aids in endodontics. Journal of Indian Academy of Oral Medicine and Radiology. 2011 Jul 1;23(3):221.

55. Tuned Aperture Computed Tomography
Works on the basis of Tomosynthesis
Less distortion and anatomical noise
Overall radiation dose not more than 1-
2 times of a conventional IOPA
Studies were conducted wherein TACT was more
diagnostically accurate over conventional 2D IOPA’s
Detected 36% more extra Mesio-Buccal canals
in Maxillary first molars and 80% more Mesio-
lingual canals in mandibular molars
Excellent for vertical root fracture detection
Saxena AS, Patle B, Lambade P. Advanced diagnostic aids in endodontics. Journal of Indian Academy of Oral Medicine and Radiology. 2011 Jul 1;23(3):221.

56. Fiber Optic Transillumination
• Extremely useful in detecting coronal fracture lines
• Dry the tooth - fibre-optic probe of 0.5mm placed in the
buccal or lingual embrasure between two adjacent teeth.
150 Watt Halogen Lamp
with a Rheostat
Carious Lesions – Dark
Shadows
No Hazards

57. Applications of FOTI in Endodontics
Strassler HE, Pitel ML. Using fiber-optic transillumination as a diagnostic aid in dental practice. compendium. 2014 Feb;35(2):80-8.

58. Thermistor
Small Thermometer – can detect
minute temperature changes
Even a drop of saliva can
change the thermal readings
Vital teeth rewarm to normal temperature after
intentional cooling below room temperature
Non vital teeth cannot regain the
same temperature once cooled
Thermistor measures this
change in temperature
Measuring thermistor – surface temperature of enamel
Reference thermistor – atmospheric temperature
Soyenkoff BC, Okun JH. Thermal conductivity measurements of dental tissues with the aid of thermistors. The Journal of the American Dental Association. 1958 Jul 1;57(1):23-30.

59. Orascope
Flexible fiberoptic intracanal visualization device
Has a 0.8mm tip
1:1 image to sensor ratio
Working portion 15mm in length
Useful in identifying intracanal anatomy
Abnormalities in root canals
Root canal calcifications
No Radiation
Not commercialized yet
Pandey D, Chaturvedi P, Shuklai V. Recent Diagnostic Aids in Endodontics.

60. Conclusion
In this era when the science has an immense growth in all fields,
the incorporation and utilization of the advanced technologies in the
field of diagnosis has proved to be a great achievement in the field of
medical and dental sciences.
The enhanced diagnostic approach includes enhanced visualization
tools to detecting the changes at cellular and molecular level.
Ultimately the goal of all health care professional is to provide better
treatment and improve the quality of life.

61. Bibliography

62. References
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Ntovas P, Loubrinis N, Maniatakos P, Rahiotis C. Evaluation of dental explorer and visual inspection for the detection of residual caries among Greek dentists. Journal of Conservative Dentistry. 2018 May 1;21(3):311.
Salgar AR, Singh SH, Podar RS, Kulkarni GP, Babel SN. Determining predictability and accuracy of thermal and electrical dental pulp tests: An in vivo study. Journal of Conservative Dentistry: JCD.
2017 Jan;20(1):46.
Sui H, Lv Y, Xiao M, Zhou L, Qiao F, Zheng J, Sun C, Fu J, Chen Y, Liu Y, Zhou J. Relationship between the difference in electric pulp test values and the diagnostic type of pulpitis. BMC Oral
Health. 2021 Dec;21(1):1-0.
Obeid AN, Barnett NJ, Dougherty G, Ward G. A critical review of laser Doppler flowmetry. Journal of medical engineering & technology. 1990 Jan 1;14(5):178-81.
Strassler HE, Pitel ML. Using fiber-optic transillumination as a diagnostic aid in dental practice. compendium. 2014 Feb;35(2):80-8.
Marmaneu-Menero A, Iranzo-Cortés JE, Almerich-Torres T, Ortolá-Síscar JC, Montiel-Company JM, Almerich-Silla JM. Diagnostic Validity of Digital Imaging Fiber-Optic Transillumination (DIFOTI)
and Near-Infrared Light Transillumination (NILT) for Caries in Dentine. Journal of clinical medicine. 2020 Feb 4;9(2):420.
Angelino K, Edlund DA, Shah P. Near-infrared imaging for detecting caries and structural deformities in teeth. IEEE journal of translational engineering in health and medicine. 2017 Apr 19;5:1-7.
Soyenkoff BC, Okun JH. Thermal conductivity measurements of dental tissues with the aid of thermistors. The Journal of the American Dental Association. 1958 Jul 1;57(1):23-30.
Pandey D, Chaturvedi P, Shuklai V. Recent Diagnostic Aids in Endodontics.
Bamzahim M, Shi XQ, Angmar-Månsson B. Occlusal caries detection and quantification by DIAGNOdent and Electronic Caries Monitor: in vitro comparison. Acta Odontologica Scandinavica. 2002 Jan 1;60(6):360-4
Li Z, Yao S, Xu J, Wu Y, Li C, He Z. Endoscopic near‐infrared dental imaging with indocyanine green: a pilot study. Annals of the New York Academy of Sciences. 2018 Jun;1421(1):88-96.
Stookey GK. Optical methods—quantitative light fluorescence. Journal of Dental Research. 2004 Jul;83(1_suppl):84-8.
Abrams S. Overcoming the challenges of caries detection using the Canary System. Oral Health. 2011 Dec;101(12):17.