3. INTRODUCTION
Correct treatment begins with correct diagnosis.
Definition of diagnosis: Diagnosis is the correct
determination, discriminative estimation & logical appraisal of
conditions found during examination as evidenced by
distinctive signs, marks & symptoms. (Grossman 13th edition)
3
4. Purpose of diagnosis
What problem
patient is
having?
Why patient is
having problem?
What treatment if
any, will be
necessary?
4
5. PROCESS OF DIAGNOSIS
Why the patient
is seeking
advice?
Ask the patient
about the
symptoms &
history that led
to visit
Objective
clinical tests
Correlation of
objective
findings with
subjective
findings &create
a definitive
differential
diagnosis
Formulation of
definitive
diagnosis
5
6. CASE HISTORY
Definition: Case history is defined as the data
concerning an individual & his or her family &
environment including the individual medical history that
may be useful in analyzing & diagnosing his or her case
or for instructional purpose.
Case history
includes
Medical history Dental history 6
7. Medical
history
Are you in good
health?
Have you been
taken any kind of
medicine or
drugs?
Do you have
High BP, diabetes,
epilepsy,
jaundice,
hepatitis, AIDS,
anemia,
Asthma?
Are you
pregnant now?
Are you allergic
to penicillin,
Local
anesthesia,
analgesics or
any other
drugs?
Have you been
taken any kind of
care of physician
during past 2
years?
7
8. Dental history
Chief complaint History of
involved tooth
Subjective
symptoms: Those
experienced &
reported to the
clinician by patient
Objective
symptoms: Those
ascertained by the
clinician through
various tests 8
9. CHIEF COMPLAINT:
The chief complaint,
usually in the patient’s
own words, is a
description of dental
problem for which the
patient seeks care.
What ever the reason,
the patient’s chief
complaint is the best
starting point for
correct diagnosis.
9
10. HISTORY OF INVOLVED TOOTH
Subjective
symptom
Type of pain:
Sharp, piercing
and lancinating
Dull, boring,
gnawing and
excruciating
Location of
pain:
Localized
pain
Diffuse pain
Duration of
pain:
Short and
specific to
stimuli
Persistent and
lingering
Spontaneous
pain
Nocturnal pain
Pain
10
11. HISTORY OF INVOLVED TOOTH
Objective symptoms
Extra oral swelling/intra
oral swelling/ sinus tract
Lymph node involved
submandibular,
submental or other
Tooth is painful on
percussion
Tissue tender on
palpation
Electric test: control tooth
respond at no. & test tooth
respond at no.
Thermal test: normal
abnormal response to heat
or cold or no response
11
20. SOFT TISSUE EXAMINATION
GINGIVA
26
• Normal:coral pink
• Abnormal:Erythmatous
red
color
• Normal : scalloped
margin with triangular
interdental papilla
• Abnormal: Rounded
margin with blunt
interdental papilla
contour
• Normal: Firm, resilient
• Abnormal: Soft &
fluctuant, spongy
consistency
21. SOFT TISSUE EXAMINATION
Periodontium: visual examination should include the soft
tissue adjacent to the involved tooth, for detection of swelling.
William’s periodontal probe should be
used routinely to determine the
periodontal status of the suspected tooth.
A significant pocket depth in the
absence of periodontal disease may
indicate root fracture.
27
22. PERCUSSION
This test enables to evalute the status of
the periodontium surrounding a 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.
A sensitive response, differing from that
of adjacent teeth, usually indicates the
presence of symptomatic apical
periodontitis.
28
24. PALPATION
Value of this test lies in locating the swelling over an
involved tooth and determining following:
Whether the tissue is
fluctuant and enlarged
sufficiently for incision &
drainage.
Presence , intensity &
location of pain.
Presence & location of
adenopathy
Presence of bone crepitus.
30
26. MOBILITY – DEPRESSIBLITY TEST
The mobility test is used to evalute the integrity of the attachment
apparatus surrounding the tooth.
Mobility is determined by moving a tooth laterally using the
handles of two operative instrument.
The amount of movement is indicative of the condition of the
periodontium ; the grater the movement , the poor the periodontal
status.
32
27. MOBILITY – DEPRESSIBLITY TEST
Miller’s tooth mobility index
• First distinguishable sign
of movement grater than
normal.
First degree
mobility
• Horizontal tooth
movement within range of
1 mm.
Second degree
mobility
• Horizontal tooth
movement grater than 1
mm or when the tooth can
be depressed.
Third degree
mobility 33
28. VARIOUS DIAGNOSTIC METHODS IN ENDODONTICS
Bite test
Staining & transillumination
Radiographs
Assessment of pulp vitality
Magnification
Microbial identification methods
34
29. BITE TEST
The bite test is useful in identifying a cracked tooth or
fractured cusp when pressure is applied in ascertain direction
to one cusp or section of the tooth.
The clinician should note whether the discomfort or pain
occurs during the act of biting or during the release of bite
force.
Pain on biting Symptomatic apical periodontitis
Pain on release of biting force Cracked tooth
The tooth slot is popular commercially available device for bite
test.
35
31. STAINING & TRANSILLUMINATION
To determine the presence of crack in the surface of tooth.
Methylene blue dye, painted on tooth surface,
will penetrate into cracked areas →
indicate the location of crack.
Transillumination → High intensity light on the exterior surface of the
tooth at CEJ → Indicate the extent of the fracture.
The part of the tooth proximal to the light source will absorb the light
& glow & area beyond fracture will not have transmitted light & gray
in color
37
32. RADIOGRAPHS
One of the most important clinical tools in making a
diagnosis.
Permits visual examination of the oral structures unseen
by naked eye.
Radiographs used in endodontics
A. intraoral periapical radiograph
B. Digital radiography
C. Cone-beam computed tomography
38
33. USES OF INTRAORAL RADIOGRAPH IN ENDODONTICS
• To visualize number, shape, length&
width of root canal
• Presence of calcified material in pulp
chamber or root canal
• Thickening of PDL
• Resorption of dentin originating within
root canal (internal resorption) or from
the root surface (external resorption)
• Resorption & extent of alveolar bone
destruction
39
34. Requirements to produce ideal radiograph
Proper
placement of
the film
Correct
angulations of
the cone in
relation to the
film &oral
structures to
prevent
distortion of
anatomical
images
Correct
exposure time
Proper
developing
technique to
ensure a clear
permeant
record
40
37. CONE-BEAM COMPUTED TOMOGRAPHY(CBCT)
Facilitated the transition from 2D to 3D approach.
Utilizes a cone-beam of ionizing radation→An X-ray
detector captures the radation on opposite
side→Resultant information is generated digitally
through a series of multi planner projection images of
field of view(FOV).
The image is captured as three-dimensional pixels
termed voxels ranging from 0.4mm to 0.076mm.
43
38. STEPS IN PROCEDURE OF CBCT
Acquisition
configuration
Image
detection
Image
reconstruction
Image display 44
39. APPLICATION OF CBCT IN ENDODONTICS
Diagnosis of periredicular
lesions
Canal visualization
Assessment of internal &
external resorption
Detection of root fracture&
other dentoalveolar trauma
Preparation for endodontic
surgery
Detection of calcific
metamorphosis
45
40. ADVANTAGES & DISADVANTAGES OF CBCT
46
Rapid scan time
Beam limitation
Image accuracy
Reduced patient radiation
dose
Interactive display modes
applicable to maxillofacial
imaging
Multiplanner information
Three-dimensional volume
rendering
Artifacts
X-ray beam related
Patient related
Scanner related
Image noise
Poor soft-tissue contrast
Advantages Disadvantages
42. ASSESSMENT OF PULP VITALITY
Major & essential part of diagnostic process.
Reproduce patients symptoms, diagnose diseased tooth
& disease.
Ideal technique: non invasive, painless, standardized,
reproducible, reliable, inexpensive, easily completed &
objective.
2 independent diagnostic test results.
48
43. Assessment of
pulp vitality
Thermal
test
Heat test
Cold test
Electric
pulp
test
Anesthetic
test
Test
cavity
Pulse
oximetry
Laser
Doppler
Flowemetry
others
Dual wavelength
spectrophotometry
Thermograph
Crown surface
temperature
Neural
sensibilility test
Pulp vascularity
test
49
44. NEURAL SENSIBILITY TEST
These are the testes indirectly tell us about the vitality
status of the pulp.
work on the principle of stimulating Pulp nerve fibers .
Do not indicate the health status & unreliable responses.
Correlation between test results & necrotic pulps only.
Assess whether necrotic or not & does not quantify the
degree of disease.
Useful : identifying diseased tooth.
50
45. THERMAL TESTS
Cold test can be used to differentiate between
reversible & irreversible pulpitis.
Heat testing is recommended when patient’ chief
complaint is pain in contact with hot liquid or food.
In irreversible pulpitis , patients complain of increased
pain secondary to heat test , while in such situation the
application of cold would cause temporary relief of pain.
Cold- faster A δ fibers: sharp localized pain.
Heat- slower C fibers: dull long lasting pain.
51
46. THERMAL TESTS
Heat test : materials used
Electric heat carrier
Hot gutta-percha stick (>65◦C)
Others
Hot water under rubber dam isolation
Hot burnisher
Hot compound
Dry polishing wheel 52
47. MECHANISM OF HEAT TEST ( VAN HASSLE'S THEORY)
Heat application for ≤ 5 seconds
↓
Vasodilatation
↓ No response
Increased intrapulpal pressure ↓
↓
Reduced neural excitation threshold Nonvital tooth
Immediate excruciating Positive response
painful response or painful similar to contralateral
response that lingers even control tooth
after removal of heat stimulus
↓ ↓
Irreversible pulpitis Healthy state
of the pulp
53
48. Cold test materials used
Endo ice 1,1,1,2 tetrafluoroethane
(temperature -26.2◦C)
CO2 snow ( temperature -78◦C)
Dichloro di fluromethane(-50◦C)
Ice cold water(32◦F)
Ethyl chloride(temperature -53◦C)
Endo frost( propane/butane mixture)
(temperature -50◦C)
54
49. MECHANISM OF COLD TEST (BRANNSTROM’ THEORY)
Application of
cold for <15
seconds
A positive
response similar
to that of
contralateral
control tooth
Healthy pulp
Short, sharp pain
that disappears
rapidly once the
stimulus is
removed
Reversible
pulpitis
An excruciating
painful response
that lingers on
even after the
stimulus is
removed
Irreversible
pulpitis
No
response
Non vital
tooth
55
50. ELECTRIC PULP TEST(EPT)
Indications:
Periodical monitoring of teeth after trauma
1-8 weeks lapse before normal response
EPT: reliable after trauma
Assessment of pulpal health before restorative
procedures
potential prosthetic abutment
Pulp preservation procedures & extensive restorations 56
51. ELECTRIC PULP TEST - RATIONALE
Current sufficient to overcome the resistance of enamel &
dentine- stimulate A δ fibers.
Sensation felt with gradually increasing level of current:
pulp responsive/ partially alive.
Ionic shift in tubules local depolarization
action potential.
A fibers: brief sharp sensation/ tingling.
No blood flow- pulp becomes anoxic & A δ fibers cease to
function 57
52. PROCEDURE OF EPT
Isolate the area of control tooth and tooth
to be tested
Test is always performed on control
tooth prior to testing the tooth
Apply electrolyte on the tooth
electrode & placed it against the dried
tooth surface
Location of probe tip:
Anterior teeth-Insical third
Posterior teeth-mid-third of the
mesiobuccal cusp of molar &buccal
cusp of premolar
Completion of circuit: lip clip is
placed over the patient’s lip in
contact with the oral mucosa.
58
54. CLINICAL INTERPRETATIONS OF PULPAL RESPONSE
TO EPT
• A positive response that occurs at the
same neural excitation threshold as the
control tooth.
Normal response
• Denotes nonvital tooth, which fails to
respond even the tester is set to the
highest electrical excitation value.
Negative response
• Denotes diseased pulp where the tooth
responds to a threshold which is less
than control tooth.
Early response
• Denotes diseased pulp where the tooth
responds at a significantly higher
electrical excitation level than
compared to control tooth.
Delayed response 60
55. CLINICAL INTERPRETATIONS OF PULPAL RESPONSE TO EPT
• When gangrenous pulp is present
in a root canal.
• Multirooted teeth in which the pulp
is partially necrotic, with some
nerve fibers still vital.
False negative response
• Extensive calcification.
• Fibrotic pulp
• Teeth with extensive restoration
• Recently traumatized teeth
• Recently erupted teeth
• High pain threshold
• Sedative medication
False positive response
61
56. ELECTRIC PULP TEST (EPT)
Advantages
Comfortable for the
patient .
Digital display.
Disadvantages
Interference with cardiac
pacemaker.
Unreliable in recently
traumatized teeth &teeth
with immature apex.
No indication about
vascular supply.
62
57. DIAGNOSTIC ACCURACY OF COLD TEST, EPT, HEAT TEST
Cold test 86%
Electric pulp test 81%
Heat test 71%
So, clinically a combination of cold test followed by EPT
is recommended.
63
58. ANESTHETIC TEST
Last resort test .
Objective: to anesthetize one tooth at a time until pain
disappears.
Either infiltration or intraligament injection useful.
If the pain cannot be identified as from maxillary or
mandibular origin, INB is given.
64
59. TEST CAVITY
Performed when other methods of diagnosis have been
failed.
Test cavity→Drilling through the enamel-dentin junction
of an unanesthetized tooth →painful sensation→some
vitality present in pulp.
65
60. PULP VASCULARITY TEST
Technologies which are being developed and which be
effective in vitality assessment.
66
Pulse
oximetry
Laser
Doppler
Flowmetry
Dual
wavelength
spectrometry
Cholesterol
liquid
crystals
Infra red
thermography
61. PULSE OXIMETERY
Non invasive.
Measure oxygen saturation levels during the administration of
anesthesia or other medication.
The pulse oximeter consists of
Pulse oximeter monitor(POM)
Pulse oximeter sensor(POS) which consists of
Two light-emitting diodes
1. To transmit red light 660nm
2. To transmit infrared light 940 nm
Photo detector on the opposite side of the vascular bed 67
62. PULSE OXIMETERY
Oxygenated & deoxygenated hemoglobin absorb different
amount of red & infrared light.
The 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 photo detector.
The relationship between the pulsatile change in the
absorption of red light & pulsatile change in the absorption of
infrared light is analyzed by pulse oximeter to determine the
saturation of arterial blood.
68
64. LASER DOPPLER FLOWMETRY
A non-invasive method to measure the blood flow.
Uses helium-neon laser light beam.
Light that contacts a moving object is Doppler shifted & signal
is produced.
As red cells represent the majority of moving object within the
tooth, measurement of back scattered light serve as an index
of pulpal blood flow.
70
65. DUAL WAVE LENGTH SPECTROMETRY
Independent of pulsatile circulation as it measures
oxygenation changes in the capillary bed rather than
supply in blood vessels.
Detects the presence or absence of oxygenated blood
at 760 & 850 nm.
71
66. PHOTO PLETHYSMOGRAPHY
Optical measurement technique to detect blood volume in the
micro-vascular bed of the tissue.
Components are:
Light source to illuminate tissue
photo-detector to measure the small changes in light intensity in
relation with changes in perfusion.
72
67. CHOLESTEROL LIQUID CRYSTALS
Introduced by Howell (1970)
Helical structure, known as chiral-nematic liquid crystals
Thermo chromic as easily affected by temperature or pressure
due to their fluidity.
Principle : teeth with intact pulp blood supply have a higher
tooth surface temperature compared with nonvital teeth.
inference
Vital: Nonvital :
Blue-green Red
Red-green Yellow
Green Yellow-red
73
68. INFRA-RED THERMOGRAPHY
Detect temperature changes as small as 0.1◦C.
Consists of
Thermal video system
Silicon close-up lens
74
69. MAGNIFICATION
Definition: viewing an object at grater size.
Advantages of magnification:
Grater precision in surgical procedure
Less operative trauma
Improved healing
More predictable treatment
75
Magnification
loupes Operating microscope
70. LOUPES
Inexpensive
Fixed magnification power < 4X.
Short coming of loupes:
No integrated light source
No digitally viewed images
Focus is adjusted through the movement of clinician’s head,
creating postural positions that may not be ergonomic.
76
71. OPERATING MICROSCOPE
Wide range of magnification
Coaxial illumination that allows light to enter even the deepest
area of examination
Easy photographic & video capture documentation
Capacity to make focus adjustment by moving the microscope
or its parts
Excellent tool for detection of cracks, additional canals,
perforations, calcification.
77
73. CULTURE METHODS
Culturing the microbial organisms has been traditional
means of examination .
It is cultivation & propagation of microorganisms in
artificial & favorable laboratory conditions.
Culture media commonly used are:
Brain heart infusion broth with 0.1% agar
Trypticase soy broth with 0.1%
Thioglycolate
Glucose ascites broth 79
74. CULTURE METHODS
80
Broad range in nature
Allow quantification of
cultivable microorganisms
Widely available
Physiologic studies are
possible.
Pathologic studies are
possible
Time consuming
Technique sensitive
Expertise & specialized
equipment required.
Not all viable bacteria can be
recovered
Samples require immediate
processing
Strict dependence on mode
of sample transport
Advantages Disadvantages
75. MOLECULAR BIOLOGY METHODS
Molecular biology methods are based on the identification of
specific biological markers present in the genes of
microorganisms that aid in precise phylogenetic classification &
identification of microorganisms.
The PCR method is at least 10-100 times more sensitive than
other identification method.
81
Polymerase
chain reaction
Broad range
PCR
Real time PCR
PCR-based
microbial typing
Nested PCR
FISH protocol
DNA-DNA
hybridization
76. MOLECULAR BIOLOGY METHODS
82
Detect both cultivated & as
yet cultivated species.
High specificity
High sensitivity
Can be used during
antimicrobial treatment
Can detect dead organisms
Qualitative or
semiquantitative
Detect one spices or few
different spices at a time.
Advantages Disadvantages
77. CONCLUSION
Arriving at a correct diagnosis requires knowledge of the
disease & their symptoms , skill to apply proper test
procedures & the art of synthesizing impressions , facts, &
experience into understanding.
The diagnostician must have a thorough knowledge of
examination procedures – percussion, palpation, probing and
pulp testing ; a knowledge of pathosis and its radiographic
and clinical manifestation ; an awareness of various
modalities of treatment.
To be added to these critical skills is the most basic skill of all,
listing to the patient. 83
