Diagnostic procedures in Endodontic

1. Diagnostic Procedures
Dr. Mohammed Alshehri BDS, AEGD, SSC-Resto, SF-DI

2. The key to effective treatment is accurate
diagnosis

3. Diagnosis
is the science of recognizing disease by means of signs,
symptoms and tests.
• PULPAL DIAGNOSIS
• PERIAPICAL DIAGNOSIS

4. Basic steps in diagnosis
• Chief complaint
• History : Medical and Dental
• Oral examination
• Differential diagnosis

5. Differential Diagnosis
Is the list of most likely and possibly diagnosis based on
available information
• The final diagnosis is only arrived at, after other diseases
on this list have been eliminated through further
investigations or consultations.

6. Prognosis
• Predicting the likely outcome of a disease based on
condition of patient and action of disease.

7. Pretreatment Considerations
• Chief Complaint
• Before initiating any treatment it is important to determine the
patients chief complaint or the problem that initiated own
words.
• It is recorded in patients own words.

8. Symptoms
• It is phenomena or signs of a departure from the normal
and indicative of illness
• Subjective symptoms- are those symptoms ascertained by
the clinician through various tests.
• Objective symptoms- viewing events or phenomenon as
they exist in the external world. Ex:cyanosis

9. Health And Medical History
• Medical history: helps identify conditions that could alter,
complicate or contra indicate proposed dental procedures.
n Communicable diseases : Viral infections like hepatitis,
AIDS that require special precaution procedures or
referral.
e Allergic or medications : Patients allergic to local
anesthetics like “Novacaine” or allergic to penicillins
may contra indicate the use of these drugs.

10. Health And Medical History
3. Systemic diseases and cardiac abnormalities: like
rheumatoid heart disease that demand less strenuous
procedures or prophylactic antibiotics coverage.
Antibiotic prophylaxis :
3. Artificial heart valve
4. History of infective endocarditis
5. Congenital heart tissue repair
6. Heart transplants

11. Health And Medical History
Antibiotic prophylaxis (cont.) :
• 2 grams amoxicillin 30-60 minutes preoperatively for adults
and 50 mg per kg for children.
• Allergic to pencillin, good choice is Clindamycin 600 mg ,
30-60 minutes before procedure.

12. Dental History
• Past dental history
• Present dental history

13. Past Dental History
• Reveals information about past dental problems and
treatment. If a patient has difficulty tolerating certain types
of procedures or has encountered problems with previous
dental care, an alteration of the treatment or environment
may help avoid future complications.

14. Present Dental History
• The most common complaint that leads to dental treatments
is pain or swelling.
• Questions like when did you first notice this (Inception),
factors that improve or worsen the condition (Provoking
factors). Factors that relieve the pain host or cold
(attenuating factors).

15. Most Common Complaints
• Pain
• Swelling
• Broken tooth
• Loose tooth
• Tooth discoloration
• Bad taste

16. Pain
• Duration of pain
• Frequency of pain
• Intensity of pain
• Localized or Referred location of pain
• Postural pain is when you bend or lie down.
• Stimulated or Spontaneous pain
• Quality of pain

17. Referred Pain
• Features :
• Never crosses the midline
• Can be referred from other teeth
• Sites :
• Other teeth
• Muscles of mastication
• Sinus respiratory system
• Cardiac muscle

18. Examination
• Extra-Oral
• Intra-Oral

19. Intra oral examination
• Soft tissue
Visual examination and palpation of buccal mucosa, buccal
vestibules, hard palate, soft palate, lips, tonsillar areas,
tongue and floor of the mouth, periodontium, sinus.
• Hard tissue
Examination of teeth

20. CLINICAL TESTS

21. CONTROL TEETH
• Include control teeth of similar type
• Provides a baseline for response
• Patient should not be told
• First application of test important

22. PALPATION
• Simple test done with finger tip using
light pressure to examine tissue
consistency and pain response.
• Presence, intensity and location of pain.
• Presence and location of adenopathy
• Presence of bone crepitus.
• Whether tissue is fluctuant and enlarged
• When infection confined to pulp
palpation is not diagnostic.

23. Percussion
• Tooth is struck with a quick, moderate
blow initially with low intensity by the
finger, then with increasing intensity by
using handle of an instruments.
• A positive response to percussion
indicates not only the presence of
inflammation of periodontal ligament
but also the degree of inflammation.

24. Pulp vitality tests
• Temporary Stopping / Gutta Percha stick
• Ice sticks and CO2 snow
• Dichloro-difluoro-methane
• Ethyl chloride spray
• Electric Pulp Tester
• Radiographs
• Trans-illumination
• Tooth Sloth

25. Cold test
• Includes air blast, cold water bath, ethylchloride sticks
of ice, carbon dioxide ice stick (-78oC)
• Kept in contact with the tooth for 5 seconds or until
patient feels pain.
• Disadvantage of carbon dioxide snow it causes
infarction lines in enamel.
• Aerosol of dichloro-difluoro-methane was introduced to
substitutecarbon dioxide snow

26. Heat Test
• Hot air
• Hot water
• Hot burnisher
• Hot gutta percha
• Hot compound
• Most commonly gutta-percha
stick used.

27. Responses To Thermal Tests
• No response • Non-vital pulp
• Mild to moderate degree of pain that • Normal
subsides within 1-2 sec after stimulus has
been removed
• Strong, momentary painful response that
subsides within 1-2 secs after stimulus is • Reversible pulpitis
removed
• Moderate to strong painful response that
lingers for several seconds or longer after
• Irreversible pulpitis
stimulus has been removed

28. Electric Pulp Tests (Ept)
• EPT is designed to stimulate a response of sensory fibres
within the pulp by electric excitation
• Disadvantages
• Cannot be used on patients having cardiac pace maker.
• Does not suggest the health or integrity of the pulp, simply
indicates the presence of vital sensory fibers with in the pulp.
• Does not provide any information about vascular supply of pulp,
which is the true determinant of pulp vitality.

29. False Positive Response with EPT
 pulp is necrotic, yet the patient feels sensation in tooth.
Why?
• Electrode or conductor in contact with metal restoration or
gingiva.
• Liquefaction necrosis may conduct current to attachment
apparatus.
• Failure to isolate and dry the teeth (saliva)

30. False Negative Response with EPT
• pulp is vital, but patient does not respond.
Why?
• Patient heavily pre-medicated with analgesics, alcohol or
tranquilizers
• Inadequate contact with electrode or conductor and enamel.
• Recently traumatized tooth
• Excessive calcification of canal.
• Recently erupted tooth with immature apex.

31. Laser Doppler Flowmetry
• A non-invasive method to measure the
blood flow.
• This technique uses a helium neon laser
light beam that is directed into the tooth.
• Light that contacts a moving object is
Doppler shifted, and a signal is produced
• As red blood cells represents the majority
of moving objects within the tooth,
measurements of back scattered light
serves as an index of PBF.

32. Pulse Oximetry
• Oximetry refers to determination of percentage of oxygen
saturation of circulating arterial blood.
• Probe sensor consists of two light emitting diodes, one to
transmit red light (640 mm) and other to transmit infra red
light (960 mm) and photo detector on opposite side of
vascular bed.
• Well oxygenated blood appears bright red (81%)

33. Test Cavity
• Performed when other diagnostic methods have failed.
• Test cavity is made by drilling through enamel dentin
junction of un-anaesthetized tooth.
• Sensitivity or pain felt is an indication of pulp vitality.

34. Mobility Test
• Rationale of mobility test is to evaluate the integrity of the
attachment apparatus surrounding the tooth.
• Test consists of moving the involved tooth facio-lingually using
handles of two instruments or using two index fingers.

35. Depressibility Test
• Test for depressibility is performed by applying pressure in
an apical direction on the occlusal / incisal aspect of tooth
and observing vertical movement if any.

36. Radiographic Examination
• Presence of caries that may involve or
threat to involve the pulp.
• May show the number, curve, length and
width of root canals.
• Presence of calcified materials in the pulp
chamber or root canals.
• Resorption of dentin
• Thickening of PDL
• Nature and extent of periapical and
alveolar bone destruction

37. Periodontal Examination
 Consists use of a blunt calibrated probe to explore
the integrity of gingival sulcus around each tooth.
 A significant pocket if present in the absence of
periodontal disease it increases the probability of
presence of vertical treatment.
 To distinguish disease of periodontal origin from
pulp origin, thermal and EPT along with PDL
probing are essential.

38. Periapical Lesions
• Inflammation results in bone resorption, and creation of
radiolucent lesion around apex.

39. Periapical lesion of endodontic origin
• Usually have 4 characteristics :
1) Lamina dura of tooth socket is lost apically
2) The radiolucency remains at apex in radiographs made at
different cone angles
3) Radiolucency tends to resemble a hanging drop
4) Tooth has a necrotic pulp

40. Pulpal lesion of endodontic origin
• Usually have :
1) Altered pulp space enlargement- internal resorption
2) Diffuse calcification in chamber
3) Pulp stones in pulp chamber
4) Canal calcifications

41. Additional Diagnostic Tests
Caries Removal
• Determining the depth of caries penetration is important
in pulp diagnosis.
• Exposure by soft caries is irreversible pulpitis.

42. Anesthetic Test
• Performed when usual tests have failed to enable one to
identify the tooth.
• Objective is to anaesthetize a single tooth at a time until the
pain disappears and is localized to specific tooth.

43. Transillumination Test
• Light from fibre optic is applied from buccal surface to
illuminate the tooth to detect fractured lines when present.

44. Indicators for difficult diagnosis
1) Patient cannot localize the pain
2) No local dental cause for the pain
3) Pain is spontaneous or intermittent and not related to an
initiating stimulus
4) Stimulation of suspected tooth does not produce the symptoms
5) Suspected tooth shows no clear etiology
6) When more than one tooth involved
7) Symptoms are bilateral
8) Selective anesthesia fails to localize the source of pain.