Endodontic diagnostic aids

Dr.P.Ravishanker,M.D.S.,

 Before initiating treatment, one must first assemble collective information regarding signs, symptoms, and history.

4 steps of diagnostic process

Assemble all available facts. Interpretation of the facts. Formulation of differential diagnosis. Operational or working diagnosis.

Symptom
Is a sign of departure from the normal and indicative of illness. Can be subjective or objective. Eg. Pain Can be sharp ,lancinatingor dull & boring.

Examination & testing.

Extra oral Look for facial asymmetry Palpate TMJ. Check mouth opening

Intra oral examination

The lips and cheeks are retracted while the teeth are in occlusal contact and the oral vestibules and buccal mucosa are examined for localized swelling and sinus tract or color changes. Particular tooth causing the complaint is readily noted.

 Using a mouth mirror and an explorer, and possibly a fiber-optic light source, the dentist carefully and thoroughly examines the suspected tooth or teeth for caries,defective restorations, discoloration. Tissue to be examined should be dried with an air syringe or gauze. Check for 3 Cs. Check for sinus tracts.

 Transillumination with a fiber-optic light, directed through the crowns of teeth, can add further information. Changes in translucency helps to distinguish between vital & non vital teeth. Transillumination may also locate teeth with vertical cracks or fractures.

Palpation

Percussion
use a mirror handle and very gently tap the occlusal/incisal surfaces of several teeth in the area in question.

Mobility
1st degree- barely perceptible horizontal movement. 2nd deg-<1mm horizontal movement 3rd deg- > 1 mm horizontal movement or vertical depressibility. How to check?

Periodontal evaluation

Pulpal evaluation
Thermal tests

Pulp tests alone are usually not adequate for establishing a diagnosis but can provide very useful information.

Cold test
used in differentiating between reversible and irreversible pulpitis and in identifying teeth with necrotic pulps. Type of response- lingering or not. In testing, if the pain lingers, that is taken as evidence for irreversible pulpitis. If pain subsides immediately after stimulus removal, hypersensitivity or reversible pulpitis is the more likely diagnosis.

How do u perform ?
Ice sticks Ethyl chloride spray Carbon di oxide snow Isolating the teeth with rubber dam & bathing each tooth with ice water from a syringe for 5 secs will elicit the most accurate response because it simultaneously cools all the surfaces of the teeth.

Heat test
Hot water baths under rubber dam isolation. Gutta percha sticks A positive response of pain, similar to the chief complaint, provides the information needed to identify the problem tooth.

Response to thermal tests

1. 2. No response Mild to moderate degree of awareness of slight pain that subsides within 1 to 2 secs after the stimulus has been removed. Strong momentary painful response that subsides within 1-2 secs after the stimulus has been removed. Lingering response.

3.
4.

Electric pulp test

 Dry the teeth to be tested and isolate them with cotton rolls. Cover the tip of the electrode with toothpaste or a similar electrical conductor. With or without gloves

Contraindications
cardiac pacemaker

False +ve

false - ve

Patient reports sensation in a tooth with necrotic pulp. Due to anxiety, saliva, metallic restorations.

Although the pulp is vital, patient does not indicate any sensation Due to drugs, immature teeth,trauma,partial necrosis with vital pulp in the apical 3rd alone.

Occlusal pressure test

The orangewood stick, the Tooth Slooth, and Burlew disks allow pinpoint testing of individual cusp areas. This test is useful in identifying teeth with symptoms of apical periodontitis, abscess, or cracks. An interesting clinical observation in patients with tooth infractions (cracked tooth syndrome) is pain often experienced when biting force is released rather than during the downward chewing motion.

Selective anesthetic test

Intra ligamentary inj of 0.2 ml of L.A. points out the involved tooth. If pain still persists afetr L.A., other causes of pain should be thought about.

Test cavity
often a last resort in testing for pulp vitality.

Radiographic examination
In the sequence of examination, radiographic evaluations should come last. it is a two-dimensional representation of a three-dimensional object.

(1) size and character of periradicular lesion, (2) curvature of root end, (3) relationship of root to adjacent roots, (4) mesial or distal inclination of root, (5) approximate length of tooth, (6) relationship of exploring instrument to root curve,

Radio-visio graphy

True indicator of pulp vitality

Blood flow Indicators Laser Doppler Flowmetry Pulsoximetry Liquid crystal testing. Hughes probeye camera