Endodontic Diagnostic Aids :Endodontic Diagnostic Aids


Slide 2:Definitions History Taking & Records Symptoms (Subjective & Objective) Radiographs Vitality Testing


Slide 3:Diagnosis is the process of identifying a disease by careful investigation of its symptoms and history An accurate diagnosis is the result of synthesis of scientific knowledge, clinical experience, intuition and common sense. The process is thus both an art and science


The four components of diagnosis :The four components of diagnosis 1.Assemble facts Chief complaint Medical & Dental history Subjective sym. History of the present condition 2. Screen & interpret the assembled clues 3. Differential Diagnosis 4. Operational or working diagnosis (Final diagnosis)


Slide 5:A proper diagnosis begins with information about the patient’s chief complaint, along with the objective findings found through clinical and radiographic examinations coupled with appropriate pulp tests


Slide 6:PATIENT QUESTIONNARE First Name:______________ Last Name:_______________ Are you experiencing any pain at this time? Yes ___ No ___ If yes, can you locate the pain? Yes ___ No ___ When did you first notice the symptoms? ________________________ Did symptoms occur suddenly or gradually? _____________________ Please check the frequency, quality and intensity of your pain LEVEL OF INTENSITY FREQUENCY QUALITY 1__ 2__ 3__ 4__ 5__ 6__ 7__ 8__ 9__ 10__ Constant__ Sharp__ Intermittent__ Dull__ Momentary__ Throbbing__ Occasional__ Do you grind or clench your teeth? Yes ___ No ___ If so, do you wear a night guard? Yes ___ No ___ Has a restoration (filling 0r crown) been placed on this tooth recently? Yes ___ No ___ Prior to this appointment, has root canal therapy been started on this tooth? Yes ___ No ___ Any past trauma or injury to this tooth? Yes ___ No ___ If yes, describe past trauma and state the occurrence date. __________________________________________________________ Is there anything else we should know about your teeth, gums or sinuses that would assist in diagnosis? __________________________________________________________


Chief Complaint :Chief Complaint Chief complaint is the history of the symptoms noted in the patient’s own words that describes the symptoms causing the discomfort History of Present Illness


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Slide 9:CLINICAL EXAMINATION VISUAL EXAMINATION: Extra oral examination Intra oral examination Soft tissues: Color Contour Consistency Sinus opening


Slide 10:COLOUR Normal crown- life like translucency Discolored opaque – inflamed, degenerated or necrotic pulp. Calcified Canal – Light Yellow Hue of the Crown Pink Tooth – Indicates Internal Resorption CROWN CONTOUR Wear Facets, Fractures and Restorations


Slide 11:PALPATION Digital pressure is used to check for tenderness in the oral tissues overlying the suspected teeth Bimanual palpation is most efficient to detect incipient swellings before it is clinically evident


Slide 12:PERCUSSION Normal resonant sound on percussion indicates good periodontal ligament Dull sound on percussion indicates ankylosis. Response to percussion not only indicates the involvement of the PDL but also the extent of the inflammation.(degree of response directly proportional to degree of inflammation). Chronic periapical inflammation is often negative to Percussion.


Slide 13:MOBILITY Tooth mobility provides an indication of the integrity of the attachment apparatus. Causes may be recent trauma, crown/root fracture, chronic bruxism, habits and orthodontic tooth movement. Grade I – Noticeable horizontal movement in its socket. Grade II – within 1 mm of horizontal movement. Grade III – Horizontal movement greater than 1 mm and/or vertical depressibility.


Radiographs :Radiographs Radiographs are an important and necessary adjunct in Endodontics. Periapical and Bite wing radiographs are mainly used. Accurate radiographic techniques and proper interpretation are essential for sound diagnosis and treatment. Radiographs are used for determining pulpal anatomy prior to access openings. Establishing working length. Confirm master cone placement and for evaluating the success of treatment.


Slide 15:Bite wing radiographs are helpful to Detect recurrent decay Detect the depth of pulp chamber. Peri radicular pathosis / bone destruction is not evident in the radiograph, until there is significant erosion of the cortical plate because bone loss is confined to the cancellous bone. With a mineral content of 52% of the cortical bone, there must be a 6.6% loss of bone mineral in order for the lesion to become radiographically visible.


Slide 16:Features seen in high quality periapical radiographs (ortho radial projection) include Caries Sharp outline of the root Tooth length Number of roots and canals Calcification Hard tissue deposits Internal/External resorption Periapical lesions Perforations Fractures


Slide 17:Vertical Root Fractures - Cannot be seen through radiographs - Look for haziness surrounding the roots Transillumination Fiber optic wand, otoscope with fiber optic attachment or fiber optic hand piece may be used. Composite curing lights are not recommended as they may illuminate the entire crown and not highlight the fracture line as with fiber optics. Tooth slooth Horizontal and oblique fractures - Two x-rays are needed to locate these fractures FRACTURES


Slide 18:Things to look for in radiographs Cervical burnout : It is a diffuse radiolucent area on the proximal side. Decreased x-ray absorption in that area should not to be confused with root caries. Lamina dura: Parallel – well defined Oblique – diffuse Thickened/dense – Heavy occlusal forces Intact lamina dura – Vital pulp


Slide 19:PULP VITALITY TESTS Assessment of vitality using routine methods rely on the stimulation of Aδ nerve fibers and there is no direct indication of the blood flow. Three methods are used to stimulate the Aδ nerve fibers Thermal stimulation Electrical stimulation Direct dentin stimulation.


Slide 20:THERMAL STIMULATION Inexpensive The temperature used is 65.5ºC to elicit the response Can use Gutta percha – (base plate gutta percha) Cast metal crown restorations are too thick to allow heated GP to elicit response In such cases a rubber wheel is used to elicit the response


Slide 21:COLD TEST Various materials used for cold test are Cones of ice - -20ºC Ethyl chloride spray - - 40ºC Carbon- di- oxide snow – -70ºC Application of cold for 4 seconds lowers the temperature to between 26 and 30ºC eliciting pain. Within the pulp temperature is lowered by 0.2ºC.


Slide 22:Heat causes vasodilatation and increase in intra pulpal pressure (releases gaseous product of proteolysis) (VAN HASSEL). In an intact pulp specific pulpal temperature must be reached before there is pain from heat. Therefore, application of heat to normal teeth gives delayed response. In a tooth with inflamed pulp, increased intra pulpal pressure already exists. Therefore immediate painful response to gradual/sudden increase in heat.


Slide 23:COLD Cold decreases intrapulpal pressure in normal intact pulp and there is no pain. The pain from cold is due to hydrodynamic mechanism. Contraction of fluid causes outward flow of fluid in dentinal tubules, deforms Aδ nerve and an action potential is generated. In advanced acute pulpitis, no Aδ receptors are present. Cold produces contraction and lowers the intrapulpal pressure to a sub threshold level and relieves pain due to still viable C fibers. Pain returns within 30 – 60 seconds as intra pulpal pressure returns to its former suprathreshold level.


Slide 24:ELECTRIC PULP TEST Electrolyte applied on the teeth to transmit current Jelly used for ECG is ideal When electrolyte contacts the tooth an electric charge is applied by pressing rheostat button. A small charge is released initially and increased until response is felt. Select control teeth – contra lateral teeth and adjacent teeth.


Slide 25:INTERPRETATION If the current required to gain a response from a test tooth is same as that needed to excite the control – the pulp of the test tooth is considered normal. If less current is required for a response – Hyperactive If more current is required– delayed response/ high pain threshold Lack of response – Pulpal necrosis


Slide 26:Two readings are recorded and the average value is taken. “Using EPT on any tooth more than 4 times can give wrong reading due to additive action.”


INTERPRETATION :INTERPRETATION If the current required to gain a response from a test tooth is same as that needed to excite the control – the pulp of the test tooth is considered normal. If less current is required for a response – Hyperactive If more current is required– delayed response/ high pain threshold Lack of response – Pulpal necrosis


Slide 28:Two readings are recorded and the average value is taken. “Using EPT on any tooth more than 4 times can give wrong reading due to additive action.”


Slide 29:Only Aδ fibers are activated by electric tests Aδ fibers produce initial momentary sharp response to electric stimuli because of its peripheral location, low threshold & greater conduction velocity. Continuous constant pain is produced by the smaller C fiber stimulation as it is associated with tissue damage and inflammatory process.


DISADVANTAGES :DISADVANTAGES Battery plug in Electrical deficiencies Output current variations Battery run down and not delivering full current all these give variable results with EPT Molars give readings not indicative of the true pulpal condition.


LIMITATIONS :LIMITATIONS Tests are not reliable on immature teeth of young patients as these teeth contain fewer Aδ fibers than mature teeth and myelinated nerves do not reach their maximal depth of penetration into the pulp until the apex completes its development.


Slide 32:When comparing teeth in question with the control teeth, pulps of the control teeth may not be normal. Teeth with acute alveolar abscess may respond positively to EPT because the gaseous and liquefied elements within the pulp can transmit electric charges to periapical tissues.


Slide 33:In traumatic injuries, in the cervical areas there will be temporary paraesthesia of the nerves. If pulp vitality remains, the pulp will respond within normal limits after 30 to 60 days.


Special Tests :Special Tests Bite test Transillumination Anesthetic test Test Cavity


Thank You :Thank You