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Dent 423; Diagnostic Tests I
Aceil Al-Khatib DDS, MS, Diplomat ABOM, LLB

Routine Dental Tests
• Vitality tests:
– Thermal: cold and heat – Electrical – Cutting an access cavity without anaesthesia



Vitality Tests
• Provide an adjunct to determining the state of pulp • Results must be interpreted with caution • False positive and false negative results are common

Vitality tests
• Surrounding and contralateral teeth should also be tested • Test should begin on a normal tooth • Stimuli should be applied to normal enamel of the crown of the tooth • Better results if more than one test is used ( heat and cold, or cold and electrical tests)



Uses Of Vitality Testing In Clinical Practice
• • • • • • Prior to operative procedures Diagnosis of pain Investigation of radiolucent areas Post-trauma assessment Assessment of anaesthesia Assessment of teeth which have been pulp capped or required deep restoration

Thermal Vitality Tests
• A temperature in the range of 20-50 C does not elicit pain from healthy teeth • Teeth with inflamed pulps (pulpitis) react with severe pain on temperature stimulation within 20-50 ْ



Cold Test
• Involves using a refrigerant, such as endo-ice, ethyl chloride spray • The middle third of the clinical crown for posterior teeth and the border between the coronal and middle thirds of the clinical crown for anterior teeth

How to Apply the Cold Test
• Hold a cotton pellet in tweezers • Spray Ethyl chloride or endo ice until crystals form • Apply the icy pellet to the facial surface of the tooth • Leave the chilled cotton pellet on the tooth for at least 10 seconds before deciding on the response







The Heat Test
• Apply to the vaseline-coated surface of the test tooth • Use a ball of softened gutta percha on the tip of a plastic instrument (gutta-percha softens at 65 C) • Place the gutta percha onto the tooth the same way you would the ice • Wait approximately 5 seconds • Compare the results from other tested teeth



A rubber cup applied to a tooth to generate frictional heat

• The use of hot water, administered through an irrigating syringe under rubber dam isolation



• May be difficult to use on posterior teeth because of limited access • Excessive heating may result in pulp damage • May result in a lingering pain, therefore heat tests should be applied for no more than 5 seconds • Inadequate heating of the gutta-percha stick could result in the stimulus being too weak to elicit a response from the pulp

Electric Pulp Test (EPT)
• EPT is technique-sensitive • The tooth must be clean and dry • The anatomic location should have no restoration, orthodontic band or brackets, or arch wire • An adequate medium ( gel, toothpaste)should be applied having contact between the tooth probe and tooth for a completed electrical circuit



How To Conduct The EPT
• Before beginning, provide the patient with specific instructions to raise a hand or arm when a sensation occurs • Clean , dry and isolate the tooth • Use a small amount of toothpaste on the metal tip of the probe • Place the tip on the middle of the facial surfaces of the tooth

How To Conduct The EPT; Cont’d
• Do not place the probe on a restorative material (metal, composite, ceramic) or touch gingival tissues • The probe should not touch lips or cheeks • Have the patient touch the handle of the device with a finger ( in order to ground the unit to complete the electric circuit) • Start by pressing and holding the start button



How To Conduct The EPT; Cont’d
• Gradually increase the voltage until a response is elicited • When the patient indicates a response, release the start button • The reading will be fixed on the display for some time after the button is released • A response to the maximum reading (e.g. reading of 64 is usually indicative that the pulp of the tooth being tested is nonvital)

• Between 0-40, the patient feels ache; vital pulp • Between 4080,with abovementioned reaction, partially vital pulp • 80, no mentioned reaction, non-vital pulp





Electrical conducting gel is present between the electrode and the tooth

A hook on the patient’s lip completes the circuit



Electric Pulp Test (EPT)
• This test should be used when the hot and cold tests fail to give clear information on the state of vitality of the tooth • Results must be compared with the response from other teeth • The most desirable area of assessment is at the incisal edge of incisor teeth, and the midthird region of posterior teeth (on the tip of the mesiobuccal cusp on molars )

False Positives From EPT Testing
• • • • Anxious patients Liquefaction necrosis Contact with metal restorations Vital tissue still present in partially necrotic root canal system



False Negatives From EPT Testing
• • • • • Incomplete root development Recently traumatized teeth Sclerosed canals Recent orthodontic activation Patients with psychotic disorders

Interpretation Of The Results Of Vitality Tests; Positive ( Normal)
• The test tooth responds in a similar way and to a similar level of stimulation to the other healthy teeth. • This result suggests that the pulp is vital



Interpretation Of An Exaggerated (prolonged) Response
• The test tooth responds more severely than and to a lower level of stimulation to the other healthy teeth. • Pain lasts for more than some 15 seconds ( minutes, hours) after removal of the stimulus • The response to heat & electrical stimulation may be greater than to cold. • Cold may reduce the pain

Interpretation Of An Exaggerated (prolonged) Response
• Irreversible pulpitis • Chronic pulpitis; if gradual reaction to heat, but not to cold or electrical stimulation leads to an exaggerated response



Interpretation Of Negative Response
• The test tooth does not respond to stimulation but healthy teeth do • The result suggests:
– Non- vital pulp – Root canals are sclerosed

False Positive
• • • • • The test unhealthy tooth responds normally; Occur in anxious or young patients Contact with metal restorations (electric test) Inadequately dried teeth ( electric test) Multi rooted teeth with one vital root canal pulp • In a root canal filled with pus or gas • In a patient with low pain threshold



False Negative
• Teeth with restorations ( heat and cold test) • Teeth with secondary dentine • Nerve supply to the pulp is damaged (e.g. trauma) • In a patient with a high pain threshold • Faulty technique or equipment

Inconclusive Result
• All teeth give similar responses: conflictive results • If the results of two tests are inconclusive add a third test • Consider cutting a diagnostic access cavity without local anaesthesia



Diagnostic Cavity Preparation
• Is the most reliable vitality test • This test may serve as a last resort in testing for pulp vitality • Is made by drilling through the enamel– dentine junction of an unanaesthetized tooth with good isolation • If the patient feels pain once the bur contacts the sound dentin, the procedure is terminated and cavity is restored

Local Anaesthetic Test
• When dental symptoms are poorly localized or referred, an accurate diagnosis is extremely difficult • Using either infiltration or an intraligamentary injection, the most posterior tooth in the area suspected of causing the pain is anaesthetized • If pain persists, the tooth immediately mesial to it is then anaesthetized, and so on, until the pain disappears



Assessment Of Pulpal Vascularity
• Crown surface temperature • Laser Doppler flowmetry: a non-invasive , painless technique with direct and objective registrations, but has limitations : environmental and technique-related factors. Nonpulpal signals, principally from periodontal blood flow, may contaminate the signal • Pulse oximetry: measure oxygen saturation levels

Laser Doppler Flowmetry (LDF)

A LDF probe applied to a sectioned tooth showing the passage of light via the enamel prisms and dentinal tubules to the pulp



A LDF trace showing signals from two teeth; the upper is from a vital tooth while the lower is from a nonvital tooth

Percussion Test
• The handle of an examination mirror or other metal handled instrument is used • The tooth is tapped to determine tenderness to percussion and the tone of percussion • Tenderness to percussion occurs when there has been injury to the periodontal ligament • Testing should begin on a healthy tooth • Must be conducted with great care



Percussion Test; Interpretation
• Percussion tone of a tooth with an intact periodontal ligament will be a low, dull sound • Percussion of an intruded tooth, locked into bone or ankylosed produces a high, metallic tone • A dull tone may suggest subluxation or extrusion of a tooth.

Percussion Test; Interpretation
• Tenderness to percussion in an apical direction: apical periodontitis • Tenderness to percussion in a lateral direction: lateral periodontitis • Digital pressure is sufficient for determining tenderness to percussion in cases of dentoalveolar trauma





• Mobility is the degree of loosening of a tooth in its socket or, in the case of alveolar fractures, the loosening of several teeth • Involves the use of two instruments or a finger and an instrument • An instrument or finger is placed buccal and an instrument is placed lingual on the tooth • Mobility of the tooth is assessed



• Horizontal tooth mobility is the ability to move the tooth in a facial-lingual direction in its socket • Vertical tooth mobility, the ability to depress the tooth in its socket

Mobility Scale
• Class 1: Slight mobility, up to 1 mm of horizontal displacement in a facial-lingual direction • Class 2: Moderate mobility, greater than 1 mm of horizontal displacement in a facial-lingual direction • Class 3: Severe mobility, greater than 1 mm of displacement in a facial-lingual direction combined with vertical displacement (tooth depressible in the socket)



Causes of Increased Mobility
Reduced bone support

Abscess or iflammation of PL
Apical periodon titis Acute trauma Occlusal trauma Periodon titis

Crown or root fracture

Bone fracture


Bony cyst


Crown root fracture



Assessments with Calibrated Probes
• Used to measure sulcus and pocket depths • Used to determine the size of an intraoral lesion or deviation • The finding of an oral lesion in a patient’s mouth should be recorded • Information recorded should include the date, size, location, color, and character of the lesion

Assessments with Calibrated Probes



Assessments with Calibrated Probes

In health, the depth of the sulcus is from 1 to 3 millimeters (mm)

Assessments with Calibrated Probes

The depth of a periodontal pocket is 6 mm



calibrated periodontal probe using customized acrylic stent for positioning the measuring probes



Guidelines for Prescribing Dental Radiographs ***
New patient, adult, dentate or partially edentulous: A full mouth intraoral radiographic exam is preferred when the patient has clinical evidence of generalized dental disease or a history of extensive dental treatment. New patient, adult, edentulous: Individualized radiographic exam, based on clinical signs and symptoms

Recall Patient***
• With clinical caries or at increased risk for caries: Posterior bitewing exam at 6-18 month intervals if proximal surfaces cannot be examined visually or with a probe • Without clinical caries or at increased risk for caries: Posterior bitewing exam at 24-36 month intervals • *** These recommendations are subject to clinical judgment and may not apply to every patient



“Radiation Protection in Dentistry”*
• “Thyroid shielding shall be provided for children, and should be provided for adults, when it will not interfere with the examination.” content/uploads/2012/06/ATA_Policy_Statem ent_June_2012.pdf*




Needle Aspiration
performed using 21–25 G needle and a 20-ml syringe without local anesthetic Is used to evaluate radiolucencies and to exclude vascular lesions



Needle Aspiration; Aspirate Yield
Negative: solid lesion Air : solitary bone cyst

Blood: vascular lesion or blood vessel

Pus: abscess or infected cyst


Fluid containing crystals: periodontal or DC



Unicystic plexiform ameloblastoma

Odontogenic keratocyst. The cyst aspirate may contain cheesy keratin debris



• The light is reflected back to the eye as different colors according to the density and physical properties of the tissues being observed, e.g. muscle and fatty tissue is usually reflected back as a reddish-orange color while the veins and arteries are reflected back as dark purple or black.



• Using a hand held transilluminator or, • A composite curing light or, • Less satisfactory is reflection of light by a dental mirror

If the entire tooth lights up, but fracture lines are visible, the fractures are generally shallow and require only monitoring. If only one portion of the tooth lights up, there is a deep crack

Fiberoptic light transillumination



Uses of Transillumination
• Tooth cracks (produces light and dark shadows at fracture sites) • Interproximal caries • Maxillary sinusitis??



Hand-held Transilluminator

Microlux Transilluminator

Caries appear as a dark shadow on the occlusal surface.



Caries Detection
Diagnodent is used as an adjunct for detection and monitoring of early occlusal caries

Healthy tooth structure exhibits little to no fluorescence, if fluorescence is detected, a value will be displayed on the screen, the higher the value, the greater the decay



Interpretation of DIAGNOdent pen Values; Diagnosis -Therapy
0 to ~13 Healthy tooth - professional tooth cleaning ~14 to ~20 Enamel caries - intensive professional cleaning with fluoridating, etc. ~21 to ~29 Deep enamel caries intensive professional cleaning with fluoridation and monitoring minimally invasive restorations - monitor caries risk factors >~30 Dentin caries - minimally invasive restorations and intensive professional cleaning