DIAGNOSIS IN ENDODONTICS
Dr.Fawad Ali Shah
Assistant
Professor
Khyber College Of
Dentistry
WHAT IS DIAGNOSIS?
What Problem patient is having ?and why
the patient is having that problem?
PURPOSE OF DIAGNOSIS
To determine the cause
Relieve any symptoms if present
Provide any treatment if necessary
STAGES OF DIAGNOSIS
The patient complains about the
problem
The clinician asks questions
about the problem
The clinician performs objective
tests
The clinician makes differential
diagnosis
The clinician performs the
definitive diagnosis
COMPONENTS OF
DIAGNOSIS
Chief complaint
Medical history
Dental history
CHIEF COMPLAINT
The reason patient
visits the clinician
Asimportant as
diagnostic tests
Helps the clinician in
formulating the
definitive diagnosis
MEDICAL HISTORY
Take proper medical
history
Document
Measure blood pressure
and pulse
Check temp and vital signs
MEDICAL HISTORY
IMPORTANCE
If there is a need to change the course of
medications for the patient with medical
condition
Medical condition having oral manifestations or
mimics dental disease
MEDICAL CONDITIONS WITH
ORAL MANIFESTATIONS
Sickle cell anemia
Multiple myloma
Tuberculosis
involving cervical and sub
mandibular lymph nodes
Iron deficiency having paresthesia of oral tissues
Acute maxillary sinusitis
Radiation of head and neck causing xerostomia
MEDICAL CONDITIONS REQUIRING
MODIFICATIONS OF DENTAL TREATMENT
Cardiovascular diseases
Gastrointestinal diseases
Renal diseases
Pulmonary diseases
Hematologic diseases
Neurologic diseases
DENTAL HISTORY
The
details of events that lead to chief
complaint is recorded as dental history
Helps in performing proper diagnostic tests
Information about past and present
symptoms
Any
trauma or procedure leading to chief
complaint
DENTAL HISTORY
QUESTIONS
Localization
Commencement
Intensity
Provocation and relief
Duration
EXAMINATION AND
TESTS
1. Extra-oral examination
2. Intra-oral examination
3. Palpation
4. Percussion
5. Mobility
6. Periodontal examination
7. Pulps tests ( Thermal and Electric)
8. Special tests
9. Radiographic examination
EXTRA-ORAL
EXAMINATION
PALPATION
VISUAL EXAMINATION
EXAMINATION
To check facial To find the nature of
asymmetry swellings like, fluctuant
or firm
Presence of extra-oral
swellings Swellings diffuse or
localized
Swellings diffuse or
localized Palpation of cervical and
submandibular lymph
Presence of sinus tracts nodes
extra-orally
INTRA-ORAL
EXAMINATION
Soft tissue examination
Intra-oral swellings
Intra-oral sinus tracts
SOFT TISSUE
EXAMINATION
Gingivaand mucosa
should be checked
Gauze piece or low
pressure air syringe
to dry soft tissues
Check color, texture,
raised lesions and
ulcerations
INTRA-ORAL SWELLINGS
Palpated to check the
nature of swelling, like
fluctuant or firm, localized or
diffuse
Present in attached gingiva,
sub-lingual tissues, alveolar
bone, palate or nasiolabial
fold
Originated from endo
lesion, perio lesion or both
INTRA-ORAL SINUS
TRACTS
Chronic endodontic lesion
Intraorally opens on the
gingival surface
Opening is called stoma
Sometimes lined with epithelium
Tracing is done through gutta
percha
Peri-apical infection with sinus tract is not
painful
But before the formation of sinus tract, there
is discomfort
Release of exudate causes relief of pain
Stoma can open in alveolar mucosa,
attacthed gingiva, furcation or gingival crevice
PALPATION
A palpation test is perfomed by applying firm digital
pressure to the mucosa covering the roots and apices
to find any peri-radicular abnormality
Positive palpation test means active peri-radicular
inflammatory process
Index finger is used to press the mucosa against the
bone
To find any soft tissue swelling or bony expansion by
comparing it to adjacent and contralateral side
PERCUSSION
Incisal
or occlusal surface is tapped
with gloved finger or back of mouth
mirror
Gentle tapping on sensitive teeth
Inform patient to reduce anxiety
Contra-lateral
tooth should be
percussed to get correct findings
Percussion shows the inflammation in the
peri-radicular region
PDL has more proprioceptors so better
localization of pain
Sowhen infection spreads to peri-
radicular region, it is very well localized
MOBILTY
Directly
propotional to the integrity of the
attachment apparatus or to the extent of
inflammation in periodontal ligament
Back ends of two mirrors are used, one on
lingual and on the buccal
Pressure is applied in bucco-lingual as
well as vertical direction
PERIODONTAL
EXAMINTION
Done with periodontal probing
Measurement of periodontal pocket depth is
the indication of gingival sulcus,
corresponding to the height of free gingival
margin and height of the attachment
apparatus
Doneon buccal and lingual aspect with
mesial, middle and distal readings
PULP TESTS
Determination of response of pulpal sensory neurons
Consists of thermal, electrical, pulse oximetry and laser
doppler flowmetry
Thermal and electrical tests determine whether pulp
nerves are intact or not
Devices detect the integrity of pulpal vasculature
Quantitative evaluation of the pulp can be only
determined histologically
THERMAL TESTS
.There are two types of tests
1. Cold testing
2. Heat testing
NORMAL RESPONSE:
Sensation is felt but is immediately removed after the removal
of stimulus
ABNORMAL RESPONSE:
1. Lack of response
2. Lingering or intensification of a painful sensation after
stimulus is removed
3. immediate, excruciatingly painful sensation as soon as
stimulus is placed on the tooth
COLD TESTING
Primary method of pulp testing
Used when no natural tooth surface is present
For porcelain jacket crown, porcelain fused to metals, full
coverage crowns
Use of rubber dam for Sticks of Ice to avoid false-positive
tests and soft tissue burns when it melts and runs into gingiva
Best results when combined with EPT
More reliable than EPT when assessing young patients with
open apices
MATERIALS:
1. Sticks of ice
2. Frozen carbon dioxide
3. Refrigerant spray
Teeth are dried and isolated, adjacent are
protected with 2x2 inches gauze piece
Applied on mid-facial aspect of teeth or
crown
Does not cause irreversible damage to
teeth or enamel crazing
Refrigerant spray is the most common
1,1,2,2 tetrafluoroethane
-26 centrigrade temperature
Easy to use and simple
HEAT TESTING
Heattesting is most useful when a
patient’s chief complaint is intense dental
pain on contact with any hot liquid or food
When patient is unable to identify the
tooth
MATERIALS:
1. An irrigating solution with
a liquid that has a
temperature similar to
what caused the painful
sensation
2. Heated gutta percha
3. Heated instruments
4. Heated compound sticks
ELECTRIC PULP TESTING
Most common device
Tells about intact nerve fibers present in pulp
No information about vasculature or histological status of
pulp
Teeth are dried and isolated
Adjacent teeth are checked first to get normal results
RESULTS: response present, lack of response, false
positive response or false negative response
Conducting medium is applied on the tip of probe
Probe is applied to the teeth
Circuit is completed when patient puts his finger on
pulp tester or when lip clip is applied to patient
Incisal third of facial aspect is checked at least twice
of suspected teeth
Readings are recorded when ‘tingling’ sensation is felt
FALSE POSITIVE
RESPONSE
CASES:
Electrodeor conductor contact with a metal
restoration or the gingiva
Patient anxiety
Liquefaction
necrosis may conduct current to
the attachment apparatus
Failure to isolate and dry the teeth before
testing
FALSE NEGATIVE
RESULTS
CASES:
Patient has been heavily pre-medicated with analgesics, narcotics,
alcohol or tranquilizers
Excessive alcohol consumption
Inadequate contact between the electrode or conductor and the
enamel
A recently traumatized tooth
Excessive calcification of the canal
Recently erupted tooth with an immature apex
Partial necrosis
LASER DOPPLER
FLOWMETRY
Isa method used to assess blood
flow in microvascular systems
Severalstudies have found LDF to be
an accurate, reliable, and
reproducible method of assessing
pulpal blood flow.
MECHANISM:
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’s
frequency will shift when hitting 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
PULSE OXIMETRY
Is a non-invasive device designed to
measure the oxygen concentration in the
blood and pulse rate
This device has been especially useful in
evaluating teeth that have been subjected
to traumatic injuries
MECHANISM:
Pulse oximeter works by transmitting two wavelengths of light, red and
infrared through a translucent portion of a patient’s body (e.g. A finger,
earlobe, or tooth)
Some of the light is absorbed as it passes through the tissue
The amount absorbed depends on the ratio of oxygenated to
deoxygenated hemoglobin in the blood
On the opposite side of the targeted tissue, a sensor detects the
absorbed light
On the basis of the difference between the light emitted and the light
received, a microprocessor calculate the pulse rate and oxygen
concentration in the blood
SPECIAL TESTS
Bite test
Test cavity
Staining and trans-illumination
Selective anesthesia
BITE TEST
When patient presents with pain while biting
For bite test to be meaningful a device
should be used that will allow the clinician
to apply pressure to individual cusps or
areas of the tooth
A variety of devices have been used for bite
tests, including
Cotton applicators
Toothpicks
Orange-wood sticks
Rubber polishing wheels
Tooth Slooth
FracFinder
TEST CAVITY
The test cavity method for assessing
pulp vitality is seldom used today.
Used when full coverage crown is
present and EPT/COLD test or
bridging technique is not applicable
The patient is not anesthetized while
this procedure is performed, and the
patient is asked to respond if any
painful sensation is felt during the
drilling procedure of making class 1
cavity
Irreversible method
STAINING AND
TRANSILLUINATION
Used to determine the presence of crack in
the surface of the tooth, interproximal
caries detection, fractures, orifice for
endodontic canals
Staining with Methylene blue dye
Transillumination with fiber-optic
light
SELECTIVE ANESTHESIA
If the patient cannot determine
which arch the pain is coming
from, then the clinician should
first anesthetize the maxillary
arch.
Itshould be understood that
periodontal ligament injections
may inadvertently anesthetize an
adjacent tooth, and thus are more
useful for identifying the arch
rather than the specific tooth.
RADIOGRAPHIC
EXAMINATION
Useful tool in diagnosis
Coupled with proper history,
clinical examination and tests
Intra-oral radiography
Digital radiography
Cone-beam computerized
tomography
INTRA-ORAL
RADIOGRAPH
For standard two-dimensional radiography,
clinicians basically project x-radiation through
an object and capture the image on a recording
medium, either x-ray film or a digital sensor
First and basic investigation
The anatomic features that are closest to the
film (or sensor) will move the least when there
is a change in the horizontal or vertical
angulation of the radiation source
Horizontal and vertical shift show additional roots, the location
of pathosis, and the unmasking of anatomic structures
It also has the potential to hide important
information
Incorrect vertical angulation may cause the buccal roots of a
maxillary molar to be masked by the zygomatic arch
Incorrect horizontal angulation may cause roots to overlap
with the roots of adjacent teeth, or it may incorrectly create the
appearance of a one-rooted tooth, when two roots are actually
present
LIMITITIONS OF
CONVENTIONAL RADIOGRAPHY
Compression of 3-D
anatomy
Geometric distortion
Anatomical
superimposition
DIGITAL RADIOGRAPHY
Ability to capture, view,
magnify, enhance, and
store images in an easily
reproducible format
Uses no X-ray films
Less radiation
It has the ability to
duplicate, store and
electronically send images
Cone beam computerized
tomography
Extra-oral
imaging
system which
can produce
3 D scan of
maxillo-facial
skeleton
When conventional radiography does not provide
sufficient information, then CBCT should be used in
cases
Early detection of apical periodontitis
Pre-surgical assessment
Assessment of dental trauma
EARLY DETECTION OF
APICAL PERIODONTITIS
PRE-SURGICAL
ASSESSMENT
ANATOMICAL
VARIATIONS
ASSESSMENT OF DENTAL
TRAUMA
THANK YOU!
