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seminar on
Examination,diagnosis and
treatment planning in endodontics
presented by-
Dr. Aman Sachdeva
PG
CONTENTS
1. Introduction
2. Examination and testing
 Extraoral examination
 Intraoral examination
3. Palpation
4. Percussion
5. Mobility
6. Periodontal examination
7. Pulp test
8. Laser Doppler flowmetry
9. Special test
• Bite test
• Test cavity
• Staining and transillumination
• Selective anaesthesia
10. Radiographic examination
11. Root fracture and cracks
12. Vertical root fracture
13. Clinical classification of pulpal and periapical diseases
I. Pulpal disease
II. Periapical disease
14 . Advancements in radiography
15. Conclusion
16. References
introduction
Endodontics is a branch of dentistry that deals with the
etiology, diagnosis, prevention and treatment of the
diseases of the pulp and periapical tissues compatible with
good health.
a. To arrive at a diagnosis, there is a definitive procedure to
be followed which involves step by step implementation of
the clinical diagnostic methods.
b. A key purpose of establishing a proper pulpal and
periapical diagnosis is to determine what clinical
treatment is needed.
c. Another important purpose of establishing universal
classification system is to allow communication
between educators, researchers and clinicians.
Definition
“The object of the practice of clinical dentistry is to
institute preventive measures, to relieve suffering, and to
cure disease. These purposes are not achieved by the
haphazard utilization of a few therapeutic formulas or of
certain mechanical procedures, but they are based on a
thorough knowledge of clinical pathology.”
- Cohen: Pathways of the Pulp, 9th Ed
Examinations & Diagonstic Procedures
a) Diagnosis cannot be made from a single isolated piece
of information .
b) The clinician must systematically gather all of the
necessary information to make a “probable” diagnosis.
c) When taking the medical and dental history, the clinician
should already be formulating in his or her mind a
preliminary but logical diagnosis, especially if there is a
chief complaint
d) The clinical and radiographic examinations in combination
with a thorough periodontal evaluation and clinical testing
(pulp and periapical tests) are then used to confirm the
preliminary diagnosis.
e) In some cases, the clinical and radiographic examinations
are inconclusive or give conflicting results and as a result,
definitive pulp and periapical diagnoses cannot be made.
f) It is also important to recognize that treatment should not
be rendered without a diagnosis and in these situations, the
patient may have to wait and be reassesed and reffered to
an endodontist.
Symptoms
I. Subjective Symptoms: Symptoms which are
experienced and reported by the patients to the
clinician.
• Chief complaint
• Character and duration of pain
• Painful stimuli
• Sensitivity to biting and pressure
ii. Objective Symptoms: Symptoms which are ascertained by
the clinician through various tests.
• Extent of decay
• Periodontal conditions surrounding the tooth
• Presence of an extensive restoration
• Tooth mobility
• Swelling or discoloration
• Pulp exposure
History and records
History taking forms an integral part of clinical
evaluations. Basically questions concerning the
patients.
1. Chief complaint
2. Past medical history
3. Past dental history are reviewed
THE CHIEF COMPLAINT
•The chief complaint is the reason the patient is
seekingcare. It is usually documented in the patient’s
words, or in the case of a young minor, the parent’s or
guardian’s words.
•This verbal description of the problem is often aided by
hand gestures and the patient pointing to a general area
of discomfort.
•After obtaining the chief complaint, the examination
process is continued by obtaining a dental history of the
present illness.
•This helps establish the correct diagnosis. Treatment
should not be rendered unless the clinician is certain
of them diagnosis.
• Patients suffering excruciating pain often have
difficulty in cooperating with the diagnostic
procedures,but until a diagnosis has been made,
treatment must not be started.
• Nonodontogenic pains need to be managed
appropriately.
Past medical history
The importance of past medical history should never be
uderestimated as this forms the backdrop of most of our
treatment plans. For ex:
1. Diabetes mellitus- (RCT/extraction) to be done only
when under check.
2. Hypertension- Extractions to be avoided. (Secondary
bleeding).
3. Cardiovascular diseases-prior antibiotic cover
anesthesia without adrenaline.
4. Renal hepatic impairment- choice of drug
5. Drug allergies
6. Asthmatics-NSAIDS to be given with caution.
7. Jaundice-Hepatitis carrier
8. Pregnancy- X-ray to be avoided.
Presentdentalillness
•Obtaining information regarding the present illness,
certain areas should be covered, such as whether there has
been any recent dental treatment.
•This information may help localize a particular problem or
give an impression of how frequently the patient seeks
dental care.
•A history of trauma is important in determining the course
of examination as well as treatment.
•Discomfort, and what triggers it, is also very important in
determining severity and urgency
History of pain
• The pulp is the formative organ of the
tooth.
• The pulp has been described as highly
resistant organ and as organ with little
resistance or recuperating ability.
• Its resistance depends on cellular activity,
nutritional supply, age and other metabolic
and physiologic parameters.
-ORBANS 11ed
• Questions should be posed in regard to the
character of pain, its location,what initiates or relieves the
symptoms, the duration of the symptoms, and what
medications the patient is taking to alleviate the
symptoms.
• Not only will this help determine the pain intensity level,
but analgesic ingestion can interfere with testing results.
The causes of pulp disease are.
1.Physical
-Mechanical
-Trauma: Accidental, Iatrogenic dental procedures
-Pathological wear
-Crack through body of tooth.
-Thermal
-Heat from cavity preparation
-Exothermic heat from setting of cements
-Electrical(dissimilar metallic filling)
2. Chemical
3. Bacterial
• Endodontics is the specialty of dentistry that
manages the prevention, diagnosis, and treatment of
the dental pulp and the periradicular tissues that
surround the root of the tooth. As an investigation,
pulp testing can have several aims
Acute Chronic
Initial Tissue damage Long term tissue
damage
Fast Process Slow process
Painful Response Lower Response
Endodontic Diagnosis
SIGNS AND SYMPTOMS OF
PULPALNERVE DAMAGE
• Pain when biting down.
• Pain when chewing.
• Sensitivity with hot or cold beverages.
• Facial swelling
• How long?
• How much has it been bothering patient?
– Any medications?
• Does any specific activity precipitate
painful episode?
– Chewing
• Prevent sleep?
History of Present Condition
ExtraoralExamination
Signs of physical limitations may be present, as well as
signs of facial asymmetry that result from facial
swelling. Visual and palpation examinations of the face
and neck are warranted to determine if swelling is
present
• The major lymph nodes of the head and neck area
should be palpated with the patient in an upright
position.
• Findings which should be noted in the patient
record include enlarged palpable nodes, fixed
nodes, tender nodes and whether the palpable
nodes are single or present in groups.
Lymph nodes palpation
• Single or multiple non-tender, and fixed nodes are
very suspicious for malignancy.
• Groups of tender nodes usually occur in conjunction
with some type of acute infection.
• Occasionally nodes will remain enlarged and palpable
after an infection.
• This is a relatively common occurrence especially
within the submandibular group of lymph nodes.
• When examined, these nodes should be small (less
than 1 cm), non-tender and mobile.
Bilateral palpation of the
occipital nodes.
Palpation of post
auricular nodes
Palpation of parotid gland
nodes
palpation of submental node
Palpation of submandibular
nodes
Palpation of
preauricular nodes
Visual & tactile inspection: The thorough visual and tactile
examination of hard & soft tissues relies on checking the 3 C’s
i.e. Color, Contour and Consistency
• Color: Any deviation from healthy coral pink color of gingiva
is easily recognizable when inflammation is present.
 Acute inflammation- fiery red color
 Chronic inflammation- dull red, bordering purple.
• Contour: swelling brings about a change in the contour of
hard or soft tissue.
• Consistency: Soft, spongy, fluctuant tissue consistency differs
from healthy, firm tissue and is indicative of underlying
pathology.
• Palpation allows the practitioner to
determine if the swelling is localized or
diffuse, firm or fluctuant.
• Extraoral facial swelling of odontogenic
origin typically is the result of
endodontic etiology because diffuse
facial swelling resulting from a
periodontal abscess is rare.
• Swellings of non odontogenic origin
must always be considered in the
differential diagnosis especially if an
obvious dental etiology is not found.
Palpation tests
• Used to determine whether the inflammatory process
has extended into the periapical tissues.
• The dentist applies firm pressure to the mucosa above
the apex of the root.
Soft Tissue Examination
• As with any dental examination, there should be a routine
evaluation of the intraoral soft tissues.
• The gingiva and mucosa should be dried, either with an air
syringe or a 2 × 2-in. gauze.
• By retracting the tongue and cheek, all of the soft tissue should
be examined for any abnormalities in color or texture.
• Any raised lesions or ulcerations should be documented and,
when necessary, evaluated with a biopsy or referral.
•Intraoral Sinus Tracts
Occasionally a chronic endodontic infection will drain through an
intraoral communication to the gingiva lsurface known as a sinus tract.
This pathway, which is sometimes lined with epithelium, extends directly
from the source of the infection to a surface opening, or stoma, on the
attached gingival surface. As previously described, it can also extend
extraorally.
The term fistula is often inappropriately used to
describe this type of drainage. The fistula by
definition is actually an abnormal communication
between two internal organs or a pathway between
two epithelium-lined surfaces.
Sinus tracts of odontogenic origin may also open
through the skin of the face.
In Hard Tissues
 Color: A normal appearing crown has a life like
translucency and sparkle, that is missing in a pulp less
tooth teeth that are discolor, opaque and less life like
should be carefully examined.
 Contours: Of crown should be examined because
fracture, wear and restorations change crown contours.
 Consistency: Of a hard tissue relates to the presence of
caries and internal and external resorption. In presence
of caries, the dentine consistency is very soft, except in
arrested caries.
Technique of Inspection: It involves the comprehensive use of
one’s eyes, fingers and explorer and the periodontal probe. The
examination of the teeth & the periodontium should always be
done under:
 dry conditions,
 having optimum light and
 most importantly using all possible barriers such as gloves,
face mask and protective eye wear.
Percussion
• Pain to percussion does not indicate that the tooth is vital or
nonvital, but is rather an indication of inflammation in the
periodontal ligament (i.e., an acute periradicular periodontitis).
• This inflammation may be secondary to physical trauma,
occlusal prematurities, periodontal disease, or the extension of
pulpal disease into the periodontal ligament space.
Percussion tests
• Used to determine whether the
inflammatory process has
extended into the periapical
tissues.
• Completed by the dentist
tapping on the incisal or occlusal
surface of the tooth in question
with the end of the mouth
mirror handle held parallel to
the long axis of the tooth.
Periapical Diagnosis
S w e l l i n g
Swelling
Drainage
Sinus Tract
Symptomatic
Apical
Periodontitis
Acute Apical
Abscess
Asymptomatic
Apical
Periodontitis
Chronic Apical
Abscess
History of pain
1. Kind of pain-
a. Sharp,piercing and lancinating- this type of painful
response is consistent with those associated with
excitation of the “a delta” nerve fibres in the pulp.
b. Dull, boring, gnawing and excruciating- this kind of
response is from those resulting from excitation and
slow rate of transmission in c nerve fibres in the pulp.
2. Location
a) Localised pain
b) Diffuse pain
3. Duration of pain
a) Short and specific to stimuli- characterised by pain of short duration
caused by a specific irritant, which disappears as soon as irritant is
removed.
b) Persistent and lingering – if the pain persists and lasts for minutes to
hours after the removal of stimuli, the pulpitis will usually be irreversible
c) Spontaneous pain- it occurs without any apparent cause and is of long
duration
d) Nocturnal pain- it occurs on changing the position of head and awakens
patient from sleep
DENTAL HISTORY CHART FOR PAIN
Nature of pain Dull Mild Moderate Severe
Quality Dull Sharp Throbbing Constant
Onset Stimulus
required
Intermittent spontaneous
Location Localized Diffuse Referred Radiating
Duration Seconds Minutes Hours Constant
Initiated By Keeps awake at
night
Cold Sweet Heat
Mastication Finger
Palpation
Relieved By Cold Heat Medicine Does not
relieved
Dentinal hypersenstivity
• It is characterised by short, sharp pain arrising
from exposed dentin in response to to stimuli
typically thermal, evaporative, tactile, osmotic
or chemical which cannot be ascribed to any
other form of dental defect or pathology.
Brannstrom’s hydrodynamic theory
stimulus
Fluid flow in exposed
dentinal tubules
Stimulation of a delta
fibres
pain
Mobility & Depressibility Testing
The mobility test is used to evaluate the integrity of the
attachment apparatus surrounding the tooth.
a. The technique consists of moving the tooth laterally in its
socket by using the handles of 2 instruments
b. The test of depressibility consists of moving the tooth
vertically in its socket. In a positive situation the chances of
saving the tooth are very poor .
Endodontic treatment should not be carried out on teeth with
grade 3 mobility unless the mobility is reduced
Periodontal Examination
• Periodontal probing is an important part of any intraoral diagnosis.
• The measurement of periodontal pocket depth is an indication of the
depth of the gingival sulcus, which corresponds to the distance
between the height of the free gingival margin and the height of the
attachment apparatus below.
Using a calibrated periodontal probe,
the clinician should record the
periodontal pocket depths on the mesial,
middle, and distal aspects of both the
buccal and lingual of the tooth, noting
the depths in millimeters
REVERSIBLE PULPITIS
• Nature of pain is mild & diffuse.
• Brief duration & can be produce cold stimuli that
elicits the pain mostly, although hot, sweet or sour
food may also initiate the pain.
• Once stimulus is removed, pain is usually subsides.
• Tooth responds to electric pulp tester at lower
currents.
• Reversible pulpitis if allowed to progress can led to
irreversible pulpitis..
IRREVERSIBLE PULPITIS
• Sharp, severe, radiating pain of long duration &
varying intensity.
• Pain continues even after the stimulus is removed.
• Pain may exacerbate with bending over or lying
down.
• Increased by stimulus, like heat & at times relieved
by cold although the cold may intensify the pain.
• When infection extends into PDL - apical
periodontitis
Glickman’s classification
Class IV Deep pocket depths indicate pathologic horizontal or vertical
bone loss.
Class I furcation defect: The furcation can be probed, but not to a
significant depth.
Class II furcation defect: The furcation can be entered into but cannot
be probed completely through to the opposite side.
Class III furcation defect: The furcation can be probed completely
through to the opposite side.
Pulp tests
Thermal Test: This test involves application of
heat and cold to a tooth, to determine sensitivity
to thermal changes.
• A positive response to cold indicates pulp
vitality regardless of whether the pulp is
normal or not. An abnormal response to heat
indicates the presence of pulpal or periapical
disorder requiring endodontic therapy.
• When a reaction to cold occurs the patient can
immediately point to the affected tooth, where
as a positive response to heat on a single tooth
results in a localized painful response which is
momentarily delayed.
Cold is the primary pulp testing method for many practitioners
today.
• To be most reliable, cold testing should be used in
conjunction with the electric pulp tester so that the results from
one test will verify the findings of the other test.
• If a mature, untraumatized tooth does not respond to both
electric pulp test and cold test, then the tooth should be
considered nonvital.
• A stream of cold air from a 3-way syringe directed against
the crown of previously dried tooth.
• Use of ethyl chloride spray (which evaporates rapidly)
absorbing heat and cooling the tooth surface.
• Application of ice sticks
• Cold water bath - Frozen carbon dioxide (CO2), also known
as “dry ice” or “carbon dioxide snow,” has been found to be
very reliable in eliciting a positive response if vital pulp tissue
is present in the tooth.
• Heat testing is most useful when a patient’s chief complaint is
intense dental pain upon contact with any hot surface.
• The heat tests can be performed using different techniques such
as
 Hot air
 Hot water
 Hot burnisher
 Hot gutta-percha
 Hot compound
 Polishing of crown with rubber cup
• An irrigating syringe is filled with a liquid (most commonly plain
water) that has a temperature similar to that which would cause the
painful sensation.
• The liquid is then expressed from the syringe onto the isolated tooth
to determine whether the response is normal or abnormal.
• The clinician moves forward in the quadrant, isolating each
individual tooth until the offending tooth is located.
• That tooth will exhibit an immediate, intense painful response to
the heat. With heat testing a delayed response may occur, so waiting
10 seconds between each heat test will allow sufficient time for any
onset of symptoms
• Another method for heat testing is to apply heated
gutta-percha or compound stick to the surface of the
tooth.
• The patient’s response to heat and cold test are
identical because the neural fibres in the pulp transmit
only the sensation of pain.
Normal
Pulp
Reversible
Pulpitis
Irreversible
Pulpitis
Necrotic
Pulp
• Electric Pulp Testing: The electric pulp
tester uses a nerve stimulation to determine
the presence of vitality. The objective is to
stimulate a pulpal response by subjecting
the tooth to an increasing degree of electric
current. A +ve response is an indication of
vitality whereas a –ve response is indicative
of pulpal necrosis
A simple technique for electrical pulp testing is as
follows.
1.Describe the test to the patient in a way that will reduce
anxiety and will eliminate a biased response.
2.Isolate the area of teeth to be tested with cotton rolls and a
saliva ejector, and air dry all the teeth.
3.Check the electric pulp tester for function, and determine
that current is passing through the electrode.
4. Apply an electrolyte (toothpaste) on the tooth
electrode, and place it against the dried enamel of the
crown’s occlusobuccal or incisolabial surface. It is
important to avoid contacting any restorations in the
tooth or the adjacent gingival tissue with the
electrolyte or the electrode; this would cause a false
and misleading response.
5. Retract the patient’s cheek away from the tooth
electrode with the free hand. This hand contact with
the patient’s cheek completes the electrical circuit.
6.Turn the rheostat slowly to introduce minimal
current into the tooth, and increase the current
slowly. Ask the patient to indicate when sensation
occurs by using such words as “tingling” or
“warmth”. Record the result according to the
numeric scale on the pulp tester.
7. Repeat the foregoing for each tooth to be tested.
Limitation of the test are:
• A false +ve response can be achieved when
moist gangrenous pulp is present in the root
canals. In multirooted teeth, when some nerve
fibers are still vital in 1 or more canals.
• A false –ve response occurs in the presence of
calcification in the pulp tissue.
• More current is needed in a tooth with
reparative dentin, diminishing size of pulp
cavity and fibrotic pulp.
Special Tests
Anaesthetic Test
• This test is restricted to patients who are in
acute pain at the time of examination and when
the usual tests have failed to enable the clinician
to identify the offending tooth
• The objective is to anaesthetize a single tooth at
a time until the pain disappears, thus localizing
the specific offending tooth.
• Technique is to start with the most posterior
tooth in the most particular arch and then shift
to the mesial.
Bite Test
• Percussion and bite tests are indicated when a
patient presents with pain while biting.
Occasionally the patient may not know which
tooth is sensitive to biting pressure, and
percussion and bite tests may help to localize
the tooth involved. The tooth may be sensitive
to biting when the pulpal pathosis has extended
into the periodontal ligament space, creating a
periradicular periodontitis, or the sensitivity
may be present secondary to a crack in the
tooth.
• A variety of devices have been used for bite
tests, including cotton applicators, toothpicks,
orangewood sticks, and rubber polishing
wheels
Test cavity
• It allows one to determine pulp vitality and
is performed only when all other tests have
failed.
• It is done by drilling the cavity in the tooth,
through the DEJ OF AN un-anaesthetized. If
a +ve response is there, medicated cement is
filled in, and the adjacent tooth is drilled.
Staining and Transillumination
• In order to determine the presence of a crack in the surface
of the tooth, the application of a stain to the area is often of
great assistance.
• Emergence of the fibreoptic as a dental instrument has been
a great aid in the use of transillumination for diagnosis. The
test requires shining a bright light from the lingual or palatal
surface of a tooth, with viewing in a darkened room.
Staining:
There are 2 methods to stain a tooth
1. Remove the filling from the suspected tooth and place 2% iodine in
the cavity preparation. The iodine stains the fracture line dark. Mix
a dye with ZnOE and place it in the cavity preparation after filling
has been removed. The dye will seep out and colour the fracture
line.
2. Have a patient chew a disclosing tablet after taking out the
filling in the suspected fractured tooth. The line will be stained.
Purpose of staining is to detect cracked tooth syndrome.
Laser Doppler Flowmetry (LDF)
• Laser Doppler Flowmetry (LDF) is a method
used to assess blood flow in microvascular
systems. Attempts are being made to adapt
this technology to assess pulpal blood flow. A
diode is used to project an infrared light beam
through the crown and pulp chamber of a
tooth. The infrared light beam is scattered as
it passes through the pulp tissue
• The Doppler principle states that the light beam
will be frequency-shifted by moving red blood
cells but will remain unshifted as it passes
through static tissue.
• The average Doppler frequency shift will
measure the velocity at which the red blood
cells are moving.
The machine is from Moor Instruments Ltd, Devon, UK and has two sets of
probes, so it is possible to record two different sites or two teeth simultaneously.
B, The two probes from the Moor laser Doppler flow meter. Note that for practical
purposes a one-probe machine is sufficient for most clinical applications
Pulse Oximetry
• The oximeter works on the principle that two
wavelengths of light transmitted by a
photoelectric diode detect oxygenated and
deoxygenated hemoglobin as they pass through
a body part to a receptor.
• The difference between the light emitted and
the light received is calculated by a
microprocessor to provide the pulse rate and
oxygen concentration in the blood.
Radiography
Radiography:
Radiographs contain information on the presence of
a. Caries involving the pulp
b. May show number, course, shape, length and width of root
canals.
c. May also show the presence of calcified material in the pulp
chamber.
d. May also show internal and external resorption.
e. Thickening of the pdl and also resorption of cementum.
f. Can also observe the nature and extent of periapical &
alveolar bone destruction.
R/F OF TOOTH
RADIOLUCENT
1. PULP.
2. PERIODONTAL LIGAMENT
SPACE.
3. BONE MARROW SPACE.
4. NUTRIENT CANALS.
RADIOPAQUE
1. ENAMEL.
2. DENTIN.
3. CEMENTUM.
4. LAMINA DURA.
5. ALVEOLAR CREST.
6. ALVEOLAR BONE.
RADIOLUCENT STRUCTURES
MAXILLA
1. INCISIVE FORAMEN.
2. INTERMAXILLARY SUTURE.
3. NASAL FOSSA.
4. LATERAL FOSSA.
5. MAXILLARY SINUS.
6. OPENING OF
NASOLACRIMAL DUCT.
MANDIBLE
1. MANDIBULAR CANAL.
2. MENTAL FORAMEN.
3. LINGUAL FORAMEN.
4. NUTRIENT CANALS.
5. SUBMANDIBULAR GLAND
FOSSA.
RADIOPAQUE STRUCTURES
MAXILLA
1. NASAL SEPTUM.
2. ANTERIOR NASAL SPINE.
3. INVERTED Y OF YENIS.
4. ZYGOMATIC PROCESS OF
MAXILLA.
5. MAXILLARY TUBEROSITY.
6. HAMULAR PROCESS.
7. PTERYGOID PLATES.
8. CORONOID PROCESS OF
MANDIBLE.
9. TIP OF NOSE.
10. NASOLABIAL FOLD.
MANDIBLE
1. EXTERNAL OBLIQUE RIDGE.
2. MYLOHYOID RIDGE.
3. MENTAL RIDGE.
4. LOWER BORDER OF
MANDIBLE.
5. GENIAL SPINES.
6. SYMPHYSIS
INTERPRETATIONS OF
TRAUMA , PULPAL AND
PERIAPICAL LESIONS
TRAUMA
CROWN FRACTURES
ENAMEL
FRACTURE
ENAMEL DENTIN
FRACTURE
ENAMEL
DENTIN PULP
FRACTURE
• CROWN ROOT #
WITHOUT PULPAL
INVOLVEMENT
• CROWN ROOT # WITH
PULPAL INVOLVEMENT
ROOT FRACTURE AND CRAZE LINES
Cracks in teeth can be divided into three basic
categories:
• Craze lines
• Fractures (also referred to as cracks)
• Split root
• Craze lines are merely cracks in the enamel that
do not extend into the dentin and either occur
naturally or develop secondary to trauma.
• They are more prevalent in adult teeth and
usually occur more in the posterior teeth.
• If light is transilluminated through the crown of
such a tooth, these craze lines may show up as
fine lines in the enamel with light being able to
transmit through them, indicating that the crack
is only superficial. Craze lines typically will not
manifest with symptoms.
• No treatment is necessary for craze lines unless
they create a cosmetic issue
• Fractures extend deeper into the dentin than
superficial craze lines and primarily extend
mesially to distally, involving the marginal
ridges.
• Dyes and transillumination are very helpful in
visualizing potential root fractures.
• Symptoms from a fractured tooth range from
none to severe pain.
HORIZONTAL ROOT FRACTURE/ SPLIT ROOT
• Split roots occur when a fracture
extends from one surface of the
tooth to another surface of the
tooth, with the tooth separating into
two segments.
• If the split is more oblique, it is
possible that once the smaller
separated segment is removed, the
tooth might still be restorable, e.g., a
fractured cusp.
• However, if the split extends below
the osseous level or involves the
pulp, the tooth may not be restorable
and endodontic treatment may not
result in a favorable prognosis.
VERTICAL ROOT FRACTURE
A severe crack in the tooth that extends longitudinally
down the long axis of the root. Often it extends
through the pulp and to the periodontium.
• It tends to be more centrally located within the
tooth, as opposed to being more oblique, and
typically traverses through the marginal ridges.
• These fractures may be present prior to
endodontic treatment, secondary to endodontic
treatment, or they may develop after endodontic
treatment has been completed.
• Because diagnosing these vertical root fractures
may be difficult, they often go unrecognized.
• Typically, these cracks lead to a split root, leaving
the tooth with a poor prognosis.
ALVEOLAR FRACTURE
RESORPTION
• Resorptive processes of the tooth structure induce changes in
radiographic structures that may be challenging both from a
diagnostic and therapeutic point of view.
• Surface resorption and repair may be seen as the body’s way of
coping with damage to the cementum, and these processes are
sometimes extensive enough to be detectable radiographically.
• In cases of trauma with pulp damage, it then becomes a
diagnostic challenge to differentiate resorption and repair from
progressive inflammatory resorption, which, when uncontrolled,
will lead to rapid loss of tooth substance.
EXTERNAL APICAL RESORPTION
INVASIVE CERVICAL
RESORPTION
APICAL REPLACEMENT
RESORPTION/DENTOALVEOLAR ANKYLOSIS
INTERNAL RESORPTION
• Internal resorptions are usually associated with
the replacement of dentin by a soft tissue with
resorbing cells causing a balloon-shaped lesion
starting from the radicular pulp.
• The radiographic end result is a round or ovoid
radiolucent area observed
• Cervical root resorption attacks dentin from
pinpoint openings in cementum at the bottom of
the gingival pocket and progresses either in
irregular pathways in all directions into dentin or
as semilunar, distinct caries- or erosion-like lesions
Orstavik’s periapical index
PULPAL LESIONS
Apical periodontitis
Symptomatic apical
periodontitis
• Localised inflamation of PDL
in the apical region
• c/f- TOP
• r/g- thickening of pdl space
Asymptomatic apical
periodontitis
• Preceded by SAP or apical
abcess
• No signs and symptoms
• r/g- smoldering lesion
periradicular bone resorption
RADIOLUCENT LESIONS
PERIAPICAL
GRANULOMA
PERIAPICAL
CYST/RADICULAR
CYST
PERIAPICAL
ABCESS
RADIO OPAQUE LESIONS
CONDENSING
OSTEITIS/CHRONIC
FOCAL SCLEROSING
OSTEITIS
SCLEROTIC
BONE/IDIOPATHIC
PERIAPICAL
OSTEOSCLEROSIS
HYPERCEMENTOSIS
Limitations of radiographs as diagnostic tools:
1. A lesion cannot be visualized if it is still in the cancellous
bone. Only when it has penetrated into the cortical bone
we get a radiolucent image. In other words….
• A periapical lesion is usually larger than its image.
• A pathologic area can be present yet be obscured by a
plate of cortical bone.
• An acute alveolar abscess in a tooth can have a normal
radiographic appearance with no apparent radiolucency.
2. A radiograph cannot be used to differentiate
reliably among a chronic abscess, a granuloma
or a cyst. An accurate diagnosis can only be
made by histopathological evidence. The
routinely accepted d/d features are:
• Granuloma: it is a dense radiolucency that is
well defined.
• Chronic alveolar abscess: it is a diffused
radiolucency showing irregular pattern of bone
destruction.
• Cyst: it is a radiolucent mass surrounded by thin
line of radioopacity.
3. The presence of periapical radiolucency does not
automatically indicate a diseased tooth.
• It may superimpose an anatomical land mark such
as maxillary sinus, medullary spaces, mental
foramen, incisive foramen.
• In many instances it may also be a disorder that is
not pulpaly related to Ameloblastoma, Malignant
tumors, Periodontal cyst, Traumatic bone cyst.
Advancements in
radiography:
1. Digital intra oral radiography:
All X-ray images are in a digital format, viewed on a
computer screen and thus requiring less than 1/3rd of the
radiation doses administered when taking conventional X-
ray film.
2. Digital OPG: These are panoramic x-rays also used in
digital format. With the latest software applications, one X-
ray image allows the dentist to investigate many different
aspects of your oral health .
3. Cone beam computed tomography (CBCT):
• Computed Tomography has evolved into an
indispensable imaging method in clinical routine.
• CT yields images of much higher contrast compared
with conventional radiography.
• It was the first method to non invasively acquire
images inside the human body that were not biased
by superimposition of distinct anatomical structure.
• CBCT is an X-ray imaging approach that provides
high resolution 3D images of the jaws & teeth.
• CBCT shoots out a cone shaped x-ray beam and
captures a large volume of area requiring minimal
amounts of generated x-rays.
• Within 10 seconds the machine rotates 360 degrees
around the head and captures 288 static images
Advantages
• Precise identification & detection of periapical lesions.
• Detection of mandibular canal.
• Complete 3D reconstruction & display from any angle.
• Patient radiation dose 5 times lower than normal CT.
• It requires only a single scan to capture the entire
object, with reduced exposure time.
3. Micro – CT:
• Recently, micro CTs, which essentially comprise
a miniaturized design of cone beam CTs –
typically used for non destructive 3D
microscopy have become commercially
available. The X-rayed measuring field is
usually as small as 2 cubic cm. in volume.
4. Tuned Aperture Computed Tomography (TACT)
• Improve accuracy in caries diagnosis because of its 3D
or pseudo 3D capabilities.
• TACT slices can be produced from an arbitrary number
of X-ray projections, each exposed from a different
angle. TACT is useful in detection of caries & recurrent
caries, periodontal bone loss, periapical lesion,
localization and TMJ bone changes.
5. MRI- Magnetic Resonance Imaging
This technique is based on the presence of specific magnetic
properties found within atomic nuclei containing protons and
neutron.
Indications:
• Aassessing diseases of TMJ.
• Cleft lip and palate.
• Tonsillitis and adenoiditis.
• Cyst and infections.
• Tumours.
Conclusion
• Endodontics is a multifaceted specialty, with much
emphasis on how cases are clinically treated. There
have been many other recent advancements—all
for the sake of achieving an optimal result during
endodontic treatment. However, these
advancements are useless if an incorrect diagnosis
is made. Testing, questioning, and reasoning are
together combined in order to achieve an accurate
diagnosis and to ultimately form an appropriate
treatment plan. The art and science of making this
diagnosis are the first steps that must be taken
before initiating any treatment.
References
1. Cohen's Pathways of pulp (First south asia ed)-
Kenneth M Hargreaves, Louis H Berman
2. Ingle's endodontics (6ed)- Ingle, Balkland,
Baumgarthner
3. Grossman’s endodontic practice- (13ed)
4. Shafer WG, Hine Mti, Levy BM. A Textbook of Oral
Pathology. Philadelphia: Saunders.
5. problem solving in endodontics Guttman(5ed)
6. Endodontic Therapy 6th Edition:By Franklin
S. Weine.
7. Textbook of operative dentistry- Nisha garg
• Endodontic diagnosis ,pathology and treatment planning –
bobby patel
• 9. Tronstad L. Root resorption – etiology, terminology and
clinical manifestations. Endod Dent Traumatol 1988
• 10. Leik K. Bakland: Root Resorption: Dental Clinics of North
America,
• 11. Fuss Z, Tsesis I, Lin S. Root resorption--diagnosis,
classification and treatment choices based on stimulation
factors. Dent Traumatol. 2003
• 12. Torabinejad M, Hong CU, Pitt Ford TR, Kaiyawasam SP.
Tissue reaction to implanted super-EBA and mineral trioxide
aggregate in the mandible of guinea pigs: a preliminary
report. J Endod. 1995
• 13. Tooth résorption Rita F. Ne, DDSVDavid E. Witherspooti,
BDSc, BEcon MSVJames L. Gutman, DDS Quintessence Int
1999

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endo diagnosis ppt friday.pptx [Autosaved].pptx

  • 1. seminar on Examination,diagnosis and treatment planning in endodontics presented by- Dr. Aman Sachdeva PG
  • 2. CONTENTS 1. Introduction 2. Examination and testing  Extraoral examination  Intraoral examination 3. Palpation 4. Percussion 5. Mobility 6. Periodontal examination 7. Pulp test 8. Laser Doppler flowmetry
  • 3. 9. Special test • Bite test • Test cavity • Staining and transillumination • Selective anaesthesia 10. Radiographic examination 11. Root fracture and cracks 12. Vertical root fracture 13. Clinical classification of pulpal and periapical diseases I. Pulpal disease II. Periapical disease 14 . Advancements in radiography 15. Conclusion 16. References
  • 4. introduction Endodontics is a branch of dentistry that deals with the etiology, diagnosis, prevention and treatment of the diseases of the pulp and periapical tissues compatible with good health. a. To arrive at a diagnosis, there is a definitive procedure to be followed which involves step by step implementation of the clinical diagnostic methods.
  • 5. b. A key purpose of establishing a proper pulpal and periapical diagnosis is to determine what clinical treatment is needed. c. Another important purpose of establishing universal classification system is to allow communication between educators, researchers and clinicians.
  • 6. Definition “The object of the practice of clinical dentistry is to institute preventive measures, to relieve suffering, and to cure disease. These purposes are not achieved by the haphazard utilization of a few therapeutic formulas or of certain mechanical procedures, but they are based on a thorough knowledge of clinical pathology.” - Cohen: Pathways of the Pulp, 9th Ed
  • 7. Examinations & Diagonstic Procedures a) Diagnosis cannot be made from a single isolated piece of information . b) The clinician must systematically gather all of the necessary information to make a “probable” diagnosis. c) When taking the medical and dental history, the clinician should already be formulating in his or her mind a preliminary but logical diagnosis, especially if there is a chief complaint
  • 8. d) The clinical and radiographic examinations in combination with a thorough periodontal evaluation and clinical testing (pulp and periapical tests) are then used to confirm the preliminary diagnosis. e) In some cases, the clinical and radiographic examinations are inconclusive or give conflicting results and as a result, definitive pulp and periapical diagnoses cannot be made. f) It is also important to recognize that treatment should not be rendered without a diagnosis and in these situations, the patient may have to wait and be reassesed and reffered to an endodontist.
  • 9. Symptoms I. Subjective Symptoms: Symptoms which are experienced and reported by the patients to the clinician. • Chief complaint • Character and duration of pain • Painful stimuli • Sensitivity to biting and pressure
  • 10. ii. Objective Symptoms: Symptoms which are ascertained by the clinician through various tests. • Extent of decay • Periodontal conditions surrounding the tooth • Presence of an extensive restoration • Tooth mobility • Swelling or discoloration • Pulp exposure
  • 11. History and records History taking forms an integral part of clinical evaluations. Basically questions concerning the patients. 1. Chief complaint 2. Past medical history 3. Past dental history are reviewed
  • 12. THE CHIEF COMPLAINT •The chief complaint is the reason the patient is seekingcare. It is usually documented in the patient’s words, or in the case of a young minor, the parent’s or guardian’s words. •This verbal description of the problem is often aided by hand gestures and the patient pointing to a general area of discomfort. •After obtaining the chief complaint, the examination process is continued by obtaining a dental history of the present illness.
  • 13. •This helps establish the correct diagnosis. Treatment should not be rendered unless the clinician is certain of them diagnosis. • Patients suffering excruciating pain often have difficulty in cooperating with the diagnostic procedures,but until a diagnosis has been made, treatment must not be started. • Nonodontogenic pains need to be managed appropriately.
  • 14. Past medical history The importance of past medical history should never be uderestimated as this forms the backdrop of most of our treatment plans. For ex: 1. Diabetes mellitus- (RCT/extraction) to be done only when under check. 2. Hypertension- Extractions to be avoided. (Secondary bleeding). 3. Cardiovascular diseases-prior antibiotic cover anesthesia without adrenaline.
  • 15. 4. Renal hepatic impairment- choice of drug 5. Drug allergies 6. Asthmatics-NSAIDS to be given with caution. 7. Jaundice-Hepatitis carrier 8. Pregnancy- X-ray to be avoided.
  • 16. Presentdentalillness •Obtaining information regarding the present illness, certain areas should be covered, such as whether there has been any recent dental treatment. •This information may help localize a particular problem or give an impression of how frequently the patient seeks dental care. •A history of trauma is important in determining the course of examination as well as treatment. •Discomfort, and what triggers it, is also very important in determining severity and urgency
  • 17. History of pain • The pulp is the formative organ of the tooth. • The pulp has been described as highly resistant organ and as organ with little resistance or recuperating ability. • Its resistance depends on cellular activity, nutritional supply, age and other metabolic and physiologic parameters. -ORBANS 11ed
  • 18. • Questions should be posed in regard to the character of pain, its location,what initiates or relieves the symptoms, the duration of the symptoms, and what medications the patient is taking to alleviate the symptoms. • Not only will this help determine the pain intensity level, but analgesic ingestion can interfere with testing results.
  • 19. The causes of pulp disease are. 1.Physical -Mechanical -Trauma: Accidental, Iatrogenic dental procedures -Pathological wear -Crack through body of tooth. -Thermal -Heat from cavity preparation -Exothermic heat from setting of cements -Electrical(dissimilar metallic filling) 2. Chemical 3. Bacterial
  • 20. • Endodontics is the specialty of dentistry that manages the prevention, diagnosis, and treatment of the dental pulp and the periradicular tissues that surround the root of the tooth. As an investigation, pulp testing can have several aims
  • 21. Acute Chronic Initial Tissue damage Long term tissue damage Fast Process Slow process Painful Response Lower Response Endodontic Diagnosis
  • 22. SIGNS AND SYMPTOMS OF PULPALNERVE DAMAGE • Pain when biting down. • Pain when chewing. • Sensitivity with hot or cold beverages. • Facial swelling
  • 23. • How long? • How much has it been bothering patient? – Any medications? • Does any specific activity precipitate painful episode? – Chewing • Prevent sleep? History of Present Condition
  • 24. ExtraoralExamination Signs of physical limitations may be present, as well as signs of facial asymmetry that result from facial swelling. Visual and palpation examinations of the face and neck are warranted to determine if swelling is present
  • 25. • The major lymph nodes of the head and neck area should be palpated with the patient in an upright position. • Findings which should be noted in the patient record include enlarged palpable nodes, fixed nodes, tender nodes and whether the palpable nodes are single or present in groups. Lymph nodes palpation
  • 26. • Single or multiple non-tender, and fixed nodes are very suspicious for malignancy. • Groups of tender nodes usually occur in conjunction with some type of acute infection. • Occasionally nodes will remain enlarged and palpable after an infection. • This is a relatively common occurrence especially within the submandibular group of lymph nodes. • When examined, these nodes should be small (less than 1 cm), non-tender and mobile.
  • 27. Bilateral palpation of the occipital nodes. Palpation of post auricular nodes Palpation of parotid gland nodes palpation of submental node Palpation of submandibular nodes Palpation of preauricular nodes
  • 28. Visual & tactile inspection: The thorough visual and tactile examination of hard & soft tissues relies on checking the 3 C’s i.e. Color, Contour and Consistency • Color: Any deviation from healthy coral pink color of gingiva is easily recognizable when inflammation is present.  Acute inflammation- fiery red color  Chronic inflammation- dull red, bordering purple. • Contour: swelling brings about a change in the contour of hard or soft tissue. • Consistency: Soft, spongy, fluctuant tissue consistency differs from healthy, firm tissue and is indicative of underlying pathology.
  • 29. • Palpation allows the practitioner to determine if the swelling is localized or diffuse, firm or fluctuant. • Extraoral facial swelling of odontogenic origin typically is the result of endodontic etiology because diffuse facial swelling resulting from a periodontal abscess is rare. • Swellings of non odontogenic origin must always be considered in the differential diagnosis especially if an obvious dental etiology is not found.
  • 30. Palpation tests • Used to determine whether the inflammatory process has extended into the periapical tissues. • The dentist applies firm pressure to the mucosa above the apex of the root.
  • 31. Soft Tissue Examination • As with any dental examination, there should be a routine evaluation of the intraoral soft tissues. • The gingiva and mucosa should be dried, either with an air syringe or a 2 × 2-in. gauze. • By retracting the tongue and cheek, all of the soft tissue should be examined for any abnormalities in color or texture. • Any raised lesions or ulcerations should be documented and, when necessary, evaluated with a biopsy or referral.
  • 32. •Intraoral Sinus Tracts Occasionally a chronic endodontic infection will drain through an intraoral communication to the gingiva lsurface known as a sinus tract. This pathway, which is sometimes lined with epithelium, extends directly from the source of the infection to a surface opening, or stoma, on the attached gingival surface. As previously described, it can also extend extraorally.
  • 33. The term fistula is often inappropriately used to describe this type of drainage. The fistula by definition is actually an abnormal communication between two internal organs or a pathway between two epithelium-lined surfaces.
  • 34. Sinus tracts of odontogenic origin may also open through the skin of the face.
  • 35. In Hard Tissues  Color: A normal appearing crown has a life like translucency and sparkle, that is missing in a pulp less tooth teeth that are discolor, opaque and less life like should be carefully examined.  Contours: Of crown should be examined because fracture, wear and restorations change crown contours.  Consistency: Of a hard tissue relates to the presence of caries and internal and external resorption. In presence of caries, the dentine consistency is very soft, except in arrested caries.
  • 36. Technique of Inspection: It involves the comprehensive use of one’s eyes, fingers and explorer and the periodontal probe. The examination of the teeth & the periodontium should always be done under:  dry conditions,  having optimum light and  most importantly using all possible barriers such as gloves, face mask and protective eye wear.
  • 37. Percussion • Pain to percussion does not indicate that the tooth is vital or nonvital, but is rather an indication of inflammation in the periodontal ligament (i.e., an acute periradicular periodontitis). • This inflammation may be secondary to physical trauma, occlusal prematurities, periodontal disease, or the extension of pulpal disease into the periodontal ligament space.
  • 38. Percussion tests • Used to determine whether the inflammatory process has extended into the periapical tissues. • Completed by the dentist tapping on the incisal or occlusal surface of the tooth in question with the end of the mouth mirror handle held parallel to the long axis of the tooth.
  • 39. Periapical Diagnosis S w e l l i n g Swelling Drainage Sinus Tract Symptomatic Apical Periodontitis Acute Apical Abscess Asymptomatic Apical Periodontitis Chronic Apical Abscess
  • 40. History of pain 1. Kind of pain- a. Sharp,piercing and lancinating- this type of painful response is consistent with those associated with excitation of the “a delta” nerve fibres in the pulp. b. Dull, boring, gnawing and excruciating- this kind of response is from those resulting from excitation and slow rate of transmission in c nerve fibres in the pulp.
  • 41. 2. Location a) Localised pain b) Diffuse pain 3. Duration of pain a) Short and specific to stimuli- characterised by pain of short duration caused by a specific irritant, which disappears as soon as irritant is removed. b) Persistent and lingering – if the pain persists and lasts for minutes to hours after the removal of stimuli, the pulpitis will usually be irreversible c) Spontaneous pain- it occurs without any apparent cause and is of long duration d) Nocturnal pain- it occurs on changing the position of head and awakens patient from sleep
  • 42. DENTAL HISTORY CHART FOR PAIN Nature of pain Dull Mild Moderate Severe Quality Dull Sharp Throbbing Constant Onset Stimulus required Intermittent spontaneous Location Localized Diffuse Referred Radiating Duration Seconds Minutes Hours Constant Initiated By Keeps awake at night Cold Sweet Heat Mastication Finger Palpation Relieved By Cold Heat Medicine Does not relieved
  • 43. Dentinal hypersenstivity • It is characterised by short, sharp pain arrising from exposed dentin in response to to stimuli typically thermal, evaporative, tactile, osmotic or chemical which cannot be ascribed to any other form of dental defect or pathology.
  • 44. Brannstrom’s hydrodynamic theory stimulus Fluid flow in exposed dentinal tubules Stimulation of a delta fibres pain
  • 45. Mobility & Depressibility Testing The mobility test is used to evaluate the integrity of the attachment apparatus surrounding the tooth. a. The technique consists of moving the tooth laterally in its socket by using the handles of 2 instruments b. The test of depressibility consists of moving the tooth vertically in its socket. In a positive situation the chances of saving the tooth are very poor . Endodontic treatment should not be carried out on teeth with grade 3 mobility unless the mobility is reduced
  • 46.
  • 47. Periodontal Examination • Periodontal probing is an important part of any intraoral diagnosis. • The measurement of periodontal pocket depth is an indication of the depth of the gingival sulcus, which corresponds to the distance between the height of the free gingival margin and the height of the attachment apparatus below. Using a calibrated periodontal probe, the clinician should record the periodontal pocket depths on the mesial, middle, and distal aspects of both the buccal and lingual of the tooth, noting the depths in millimeters
  • 48. REVERSIBLE PULPITIS • Nature of pain is mild & diffuse. • Brief duration & can be produce cold stimuli that elicits the pain mostly, although hot, sweet or sour food may also initiate the pain. • Once stimulus is removed, pain is usually subsides. • Tooth responds to electric pulp tester at lower currents. • Reversible pulpitis if allowed to progress can led to irreversible pulpitis..
  • 49. IRREVERSIBLE PULPITIS • Sharp, severe, radiating pain of long duration & varying intensity. • Pain continues even after the stimulus is removed. • Pain may exacerbate with bending over or lying down. • Increased by stimulus, like heat & at times relieved by cold although the cold may intensify the pain. • When infection extends into PDL - apical periodontitis
  • 50. Glickman’s classification Class IV Deep pocket depths indicate pathologic horizontal or vertical bone loss. Class I furcation defect: The furcation can be probed, but not to a significant depth. Class II furcation defect: The furcation can be entered into but cannot be probed completely through to the opposite side. Class III furcation defect: The furcation can be probed completely through to the opposite side.
  • 51.
  • 53. Thermal Test: This test involves application of heat and cold to a tooth, to determine sensitivity to thermal changes. • A positive response to cold indicates pulp vitality regardless of whether the pulp is normal or not. An abnormal response to heat indicates the presence of pulpal or periapical disorder requiring endodontic therapy. • When a reaction to cold occurs the patient can immediately point to the affected tooth, where as a positive response to heat on a single tooth results in a localized painful response which is momentarily delayed.
  • 54. Cold is the primary pulp testing method for many practitioners today. • To be most reliable, cold testing should be used in conjunction with the electric pulp tester so that the results from one test will verify the findings of the other test. • If a mature, untraumatized tooth does not respond to both electric pulp test and cold test, then the tooth should be considered nonvital.
  • 55. • A stream of cold air from a 3-way syringe directed against the crown of previously dried tooth. • Use of ethyl chloride spray (which evaporates rapidly) absorbing heat and cooling the tooth surface. • Application of ice sticks
  • 56. • Cold water bath - Frozen carbon dioxide (CO2), also known as “dry ice” or “carbon dioxide snow,” has been found to be very reliable in eliciting a positive response if vital pulp tissue is present in the tooth.
  • 57. • Heat testing is most useful when a patient’s chief complaint is intense dental pain upon contact with any hot surface. • The heat tests can be performed using different techniques such as  Hot air  Hot water  Hot burnisher  Hot gutta-percha  Hot compound  Polishing of crown with rubber cup
  • 58. • An irrigating syringe is filled with a liquid (most commonly plain water) that has a temperature similar to that which would cause the painful sensation. • The liquid is then expressed from the syringe onto the isolated tooth to determine whether the response is normal or abnormal. • The clinician moves forward in the quadrant, isolating each individual tooth until the offending tooth is located. • That tooth will exhibit an immediate, intense painful response to the heat. With heat testing a delayed response may occur, so waiting 10 seconds between each heat test will allow sufficient time for any onset of symptoms
  • 59. • Another method for heat testing is to apply heated gutta-percha or compound stick to the surface of the tooth. • The patient’s response to heat and cold test are identical because the neural fibres in the pulp transmit only the sensation of pain.
  • 61. • Electric Pulp Testing: The electric pulp tester uses a nerve stimulation to determine the presence of vitality. The objective is to stimulate a pulpal response by subjecting the tooth to an increasing degree of electric current. A +ve response is an indication of vitality whereas a –ve response is indicative of pulpal necrosis
  • 62. A simple technique for electrical pulp testing is as follows. 1.Describe the test to the patient in a way that will reduce anxiety and will eliminate a biased response. 2.Isolate the area of teeth to be tested with cotton rolls and a saliva ejector, and air dry all the teeth. 3.Check the electric pulp tester for function, and determine that current is passing through the electrode.
  • 63. 4. Apply an electrolyte (toothpaste) on the tooth electrode, and place it against the dried enamel of the crown’s occlusobuccal or incisolabial surface. It is important to avoid contacting any restorations in the tooth or the adjacent gingival tissue with the electrolyte or the electrode; this would cause a false and misleading response. 5. Retract the patient’s cheek away from the tooth electrode with the free hand. This hand contact with the patient’s cheek completes the electrical circuit.
  • 64. 6.Turn the rheostat slowly to introduce minimal current into the tooth, and increase the current slowly. Ask the patient to indicate when sensation occurs by using such words as “tingling” or “warmth”. Record the result according to the numeric scale on the pulp tester. 7. Repeat the foregoing for each tooth to be tested.
  • 65. Limitation of the test are: • A false +ve response can be achieved when moist gangrenous pulp is present in the root canals. In multirooted teeth, when some nerve fibers are still vital in 1 or more canals. • A false –ve response occurs in the presence of calcification in the pulp tissue. • More current is needed in a tooth with reparative dentin, diminishing size of pulp cavity and fibrotic pulp.
  • 67. Anaesthetic Test • This test is restricted to patients who are in acute pain at the time of examination and when the usual tests have failed to enable the clinician to identify the offending tooth • The objective is to anaesthetize a single tooth at a time until the pain disappears, thus localizing the specific offending tooth. • Technique is to start with the most posterior tooth in the most particular arch and then shift to the mesial.
  • 68. Bite Test • Percussion and bite tests are indicated when a patient presents with pain while biting. Occasionally the patient may not know which tooth is sensitive to biting pressure, and percussion and bite tests may help to localize the tooth involved. The tooth may be sensitive to biting when the pulpal pathosis has extended into the periodontal ligament space, creating a periradicular periodontitis, or the sensitivity may be present secondary to a crack in the tooth.
  • 69. • A variety of devices have been used for bite tests, including cotton applicators, toothpicks, orangewood sticks, and rubber polishing wheels
  • 70. Test cavity • It allows one to determine pulp vitality and is performed only when all other tests have failed. • It is done by drilling the cavity in the tooth, through the DEJ OF AN un-anaesthetized. If a +ve response is there, medicated cement is filled in, and the adjacent tooth is drilled.
  • 71. Staining and Transillumination • In order to determine the presence of a crack in the surface of the tooth, the application of a stain to the area is often of great assistance. • Emergence of the fibreoptic as a dental instrument has been a great aid in the use of transillumination for diagnosis. The test requires shining a bright light from the lingual or palatal surface of a tooth, with viewing in a darkened room.
  • 72. Staining: There are 2 methods to stain a tooth 1. Remove the filling from the suspected tooth and place 2% iodine in the cavity preparation. The iodine stains the fracture line dark. Mix a dye with ZnOE and place it in the cavity preparation after filling has been removed. The dye will seep out and colour the fracture line. 2. Have a patient chew a disclosing tablet after taking out the filling in the suspected fractured tooth. The line will be stained. Purpose of staining is to detect cracked tooth syndrome.
  • 73. Laser Doppler Flowmetry (LDF) • Laser Doppler Flowmetry (LDF) is a method used to assess blood flow in microvascular systems. Attempts are being made to adapt this technology to assess pulpal blood flow. A diode is used to project an infrared light beam through the crown and pulp chamber of a tooth. The infrared light beam is scattered as it passes through the pulp tissue
  • 74. • The Doppler principle states that the light beam will be frequency-shifted by moving red blood cells but will remain unshifted as it passes through static tissue. • The average Doppler frequency shift will measure the velocity at which the red blood cells are moving.
  • 75. The machine is from Moor Instruments Ltd, Devon, UK and has two sets of probes, so it is possible to record two different sites or two teeth simultaneously. B, The two probes from the Moor laser Doppler flow meter. Note that for practical purposes a one-probe machine is sufficient for most clinical applications
  • 76. Pulse Oximetry • The oximeter works on the principle that two wavelengths of light transmitted by a photoelectric diode detect oxygenated and deoxygenated hemoglobin as they pass through a body part to a receptor. • The difference between the light emitted and the light received is calculated by a microprocessor to provide the pulse rate and oxygen concentration in the blood.
  • 78. Radiography: Radiographs contain information on the presence of a. Caries involving the pulp b. May show number, course, shape, length and width of root canals. c. May also show the presence of calcified material in the pulp chamber. d. May also show internal and external resorption. e. Thickening of the pdl and also resorption of cementum. f. Can also observe the nature and extent of periapical & alveolar bone destruction.
  • 79. R/F OF TOOTH RADIOLUCENT 1. PULP. 2. PERIODONTAL LIGAMENT SPACE. 3. BONE MARROW SPACE. 4. NUTRIENT CANALS. RADIOPAQUE 1. ENAMEL. 2. DENTIN. 3. CEMENTUM. 4. LAMINA DURA. 5. ALVEOLAR CREST. 6. ALVEOLAR BONE.
  • 80. RADIOLUCENT STRUCTURES MAXILLA 1. INCISIVE FORAMEN. 2. INTERMAXILLARY SUTURE. 3. NASAL FOSSA. 4. LATERAL FOSSA. 5. MAXILLARY SINUS. 6. OPENING OF NASOLACRIMAL DUCT. MANDIBLE 1. MANDIBULAR CANAL. 2. MENTAL FORAMEN. 3. LINGUAL FORAMEN. 4. NUTRIENT CANALS. 5. SUBMANDIBULAR GLAND FOSSA.
  • 81. RADIOPAQUE STRUCTURES MAXILLA 1. NASAL SEPTUM. 2. ANTERIOR NASAL SPINE. 3. INVERTED Y OF YENIS. 4. ZYGOMATIC PROCESS OF MAXILLA. 5. MAXILLARY TUBEROSITY. 6. HAMULAR PROCESS. 7. PTERYGOID PLATES. 8. CORONOID PROCESS OF MANDIBLE. 9. TIP OF NOSE. 10. NASOLABIAL FOLD. MANDIBLE 1. EXTERNAL OBLIQUE RIDGE. 2. MYLOHYOID RIDGE. 3. MENTAL RIDGE. 4. LOWER BORDER OF MANDIBLE. 5. GENIAL SPINES. 6. SYMPHYSIS
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  • 95. INTERPRETATIONS OF TRAUMA , PULPAL AND PERIAPICAL LESIONS
  • 97. • CROWN ROOT # WITHOUT PULPAL INVOLVEMENT • CROWN ROOT # WITH PULPAL INVOLVEMENT
  • 98. ROOT FRACTURE AND CRAZE LINES Cracks in teeth can be divided into three basic categories: • Craze lines • Fractures (also referred to as cracks) • Split root
  • 99. • Craze lines are merely cracks in the enamel that do not extend into the dentin and either occur naturally or develop secondary to trauma. • They are more prevalent in adult teeth and usually occur more in the posterior teeth. • If light is transilluminated through the crown of such a tooth, these craze lines may show up as fine lines in the enamel with light being able to transmit through them, indicating that the crack is only superficial. Craze lines typically will not manifest with symptoms. • No treatment is necessary for craze lines unless they create a cosmetic issue
  • 100. • Fractures extend deeper into the dentin than superficial craze lines and primarily extend mesially to distally, involving the marginal ridges. • Dyes and transillumination are very helpful in visualizing potential root fractures. • Symptoms from a fractured tooth range from none to severe pain.
  • 101. HORIZONTAL ROOT FRACTURE/ SPLIT ROOT • Split roots occur when a fracture extends from one surface of the tooth to another surface of the tooth, with the tooth separating into two segments. • If the split is more oblique, it is possible that once the smaller separated segment is removed, the tooth might still be restorable, e.g., a fractured cusp. • However, if the split extends below the osseous level or involves the pulp, the tooth may not be restorable and endodontic treatment may not result in a favorable prognosis.
  • 102. VERTICAL ROOT FRACTURE A severe crack in the tooth that extends longitudinally down the long axis of the root. Often it extends through the pulp and to the periodontium.
  • 103. • It tends to be more centrally located within the tooth, as opposed to being more oblique, and typically traverses through the marginal ridges. • These fractures may be present prior to endodontic treatment, secondary to endodontic treatment, or they may develop after endodontic treatment has been completed. • Because diagnosing these vertical root fractures may be difficult, they often go unrecognized. • Typically, these cracks lead to a split root, leaving the tooth with a poor prognosis.
  • 105. RESORPTION • Resorptive processes of the tooth structure induce changes in radiographic structures that may be challenging both from a diagnostic and therapeutic point of view. • Surface resorption and repair may be seen as the body’s way of coping with damage to the cementum, and these processes are sometimes extensive enough to be detectable radiographically. • In cases of trauma with pulp damage, it then becomes a diagnostic challenge to differentiate resorption and repair from progressive inflammatory resorption, which, when uncontrolled, will lead to rapid loss of tooth substance.
  • 106. EXTERNAL APICAL RESORPTION INVASIVE CERVICAL RESORPTION
  • 108. INTERNAL RESORPTION • Internal resorptions are usually associated with the replacement of dentin by a soft tissue with resorbing cells causing a balloon-shaped lesion starting from the radicular pulp. • The radiographic end result is a round or ovoid radiolucent area observed
  • 109. • Cervical root resorption attacks dentin from pinpoint openings in cementum at the bottom of the gingival pocket and progresses either in irregular pathways in all directions into dentin or as semilunar, distinct caries- or erosion-like lesions
  • 112. Apical periodontitis Symptomatic apical periodontitis • Localised inflamation of PDL in the apical region • c/f- TOP • r/g- thickening of pdl space Asymptomatic apical periodontitis • Preceded by SAP or apical abcess • No signs and symptoms • r/g- smoldering lesion periradicular bone resorption
  • 114. RADIO OPAQUE LESIONS CONDENSING OSTEITIS/CHRONIC FOCAL SCLEROSING OSTEITIS SCLEROTIC BONE/IDIOPATHIC PERIAPICAL OSTEOSCLEROSIS HYPERCEMENTOSIS
  • 115. Limitations of radiographs as diagnostic tools: 1. A lesion cannot be visualized if it is still in the cancellous bone. Only when it has penetrated into the cortical bone we get a radiolucent image. In other words…. • A periapical lesion is usually larger than its image. • A pathologic area can be present yet be obscured by a plate of cortical bone. • An acute alveolar abscess in a tooth can have a normal radiographic appearance with no apparent radiolucency.
  • 116. 2. A radiograph cannot be used to differentiate reliably among a chronic abscess, a granuloma or a cyst. An accurate diagnosis can only be made by histopathological evidence. The routinely accepted d/d features are: • Granuloma: it is a dense radiolucency that is well defined. • Chronic alveolar abscess: it is a diffused radiolucency showing irregular pattern of bone destruction. • Cyst: it is a radiolucent mass surrounded by thin line of radioopacity.
  • 117. 3. The presence of periapical radiolucency does not automatically indicate a diseased tooth. • It may superimpose an anatomical land mark such as maxillary sinus, medullary spaces, mental foramen, incisive foramen. • In many instances it may also be a disorder that is not pulpaly related to Ameloblastoma, Malignant tumors, Periodontal cyst, Traumatic bone cyst.
  • 119. 1. Digital intra oral radiography: All X-ray images are in a digital format, viewed on a computer screen and thus requiring less than 1/3rd of the radiation doses administered when taking conventional X- ray film. 2. Digital OPG: These are panoramic x-rays also used in digital format. With the latest software applications, one X- ray image allows the dentist to investigate many different aspects of your oral health .
  • 120. 3. Cone beam computed tomography (CBCT): • Computed Tomography has evolved into an indispensable imaging method in clinical routine. • CT yields images of much higher contrast compared with conventional radiography. • It was the first method to non invasively acquire images inside the human body that were not biased by superimposition of distinct anatomical structure.
  • 121. • CBCT is an X-ray imaging approach that provides high resolution 3D images of the jaws & teeth. • CBCT shoots out a cone shaped x-ray beam and captures a large volume of area requiring minimal amounts of generated x-rays. • Within 10 seconds the machine rotates 360 degrees around the head and captures 288 static images
  • 122.
  • 123. Advantages • Precise identification & detection of periapical lesions. • Detection of mandibular canal. • Complete 3D reconstruction & display from any angle. • Patient radiation dose 5 times lower than normal CT. • It requires only a single scan to capture the entire object, with reduced exposure time.
  • 124. 3. Micro – CT: • Recently, micro CTs, which essentially comprise a miniaturized design of cone beam CTs – typically used for non destructive 3D microscopy have become commercially available. The X-rayed measuring field is usually as small as 2 cubic cm. in volume.
  • 125. 4. Tuned Aperture Computed Tomography (TACT) • Improve accuracy in caries diagnosis because of its 3D or pseudo 3D capabilities. • TACT slices can be produced from an arbitrary number of X-ray projections, each exposed from a different angle. TACT is useful in detection of caries & recurrent caries, periodontal bone loss, periapical lesion, localization and TMJ bone changes.
  • 126. 5. MRI- Magnetic Resonance Imaging This technique is based on the presence of specific magnetic properties found within atomic nuclei containing protons and neutron. Indications: • Aassessing diseases of TMJ. • Cleft lip and palate. • Tonsillitis and adenoiditis. • Cyst and infections. • Tumours.
  • 127. Conclusion • Endodontics is a multifaceted specialty, with much emphasis on how cases are clinically treated. There have been many other recent advancements—all for the sake of achieving an optimal result during endodontic treatment. However, these advancements are useless if an incorrect diagnosis is made. Testing, questioning, and reasoning are together combined in order to achieve an accurate diagnosis and to ultimately form an appropriate treatment plan. The art and science of making this diagnosis are the first steps that must be taken before initiating any treatment.
  • 128. References 1. Cohen's Pathways of pulp (First south asia ed)- Kenneth M Hargreaves, Louis H Berman 2. Ingle's endodontics (6ed)- Ingle, Balkland, Baumgarthner 3. Grossman’s endodontic practice- (13ed) 4. Shafer WG, Hine Mti, Levy BM. A Textbook of Oral Pathology. Philadelphia: Saunders. 5. problem solving in endodontics Guttman(5ed) 6. Endodontic Therapy 6th Edition:By Franklin S. Weine. 7. Textbook of operative dentistry- Nisha garg
  • 129. • Endodontic diagnosis ,pathology and treatment planning – bobby patel • 9. Tronstad L. Root resorption – etiology, terminology and clinical manifestations. Endod Dent Traumatol 1988 • 10. Leik K. Bakland: Root Resorption: Dental Clinics of North America, • 11. Fuss Z, Tsesis I, Lin S. Root resorption--diagnosis, classification and treatment choices based on stimulation factors. Dent Traumatol. 2003 • 12. Torabinejad M, Hong CU, Pitt Ford TR, Kaiyawasam SP. Tissue reaction to implanted super-EBA and mineral trioxide aggregate in the mandible of guinea pigs: a preliminary report. J Endod. 1995 • 13. Tooth résorption Rita F. Ne, DDSVDavid E. Witherspooti, BDSc, BEcon MSVJames L. Gutman, DDS Quintessence Int 1999