SOME BASIC CLINICAL METHODS IN DENTAL EXAMINATION

1. STEPS
to
DIAGNOSE
TEETH
Dr. Sarang Suresh Hotchandani1

2. 1. TAKE GOOD HISTORY
• Listen to everything the patient wants to say. Not only will you get
useful information, but you are letting the patient know that you
have time and concern for him or her.
• What do you think the problem is?
• Does it hurt to hot or cold?
• Does it hurt when you’re chewing?
• When does it start hurting?
• How bad is the pain?
• Does anything relieve it?
• How long has it been hurting?
DR. SARANG SURESH HOTCHANDANI 2

3. 2. TAKE a RADIOGRAPH
•It may show a periapical or
periodontal area, decay,
resorption, deep fillings, fracture,
or thickened PDL. Radiographs are
indispensable. No diagnosis should
be made without them.
DR. SARANG SURESH HOTCHANDANI 3

4. 3. Percuss & Tap
• Percussion-tapping with the mirror handle on the tooth in a
vertical direction often allows you to identify the tooth that
has inflammation in the ligament and, consequently, hurts
the most to tapping.
• If two teeth together hurt to tapping, immobilize one with
your finger while tapping the other and then reverse the
process. Often you will find that one hurts significantly
more than the other and will be the more suspicious of the
two. DR. SARANG SURESH HOTCHANDANI 4

5. 4. Palpate
• Press into the fold above the apex of the root or
roots.
• Often the endodontically involved tooth will be more tender than
the others if the inflammation has extended into the periapical
region, and palpating in this way will produce a greater sensation.
• You should also be able to detect any swellings or
fistulas that may be present. Palpate the lingual of
teeth with the same goals in mind .
DR. SARANG SURESH HOTCHANDANI 5

6. 5. Cold Test
• This is simply done with cylindrically shaped ice sticks. Make
them by placing water in empty anesthetic carpules and adding
a piece of dental floss that extends to the bottom of the carpule
and has a handle on the open end of the carpule. Keep them in
the freezer and withdraw the frozen cylinder when needed.
• A good site of cold application is generally the buccal surface as
close to the cemento-enamel junction as possible. If a metal
crown restoration is on the tooth, attempt to apply the ice on
the lingual metal collar, an area where the cold travels most
easily.
DR. SARANG SURESH HOTCHANDANI 6

7. 5. Cold Test
• If a tooth has irreversible pulpitis it will either give a
prolonged response, possibly after some delay, or no
response. Transient pain (less than ten seconds) after the
application and removal of ice is normal. No response may
mean the tooth is endodontically involved, especially if all
other teeth respond to cold.
• If sharp transient pain occurs that is greater than the pain
felt in surrounding teeth, check to see if the bite is high.
Root canal is probably not needed and the bite adjustment
will eliminate the hyper response to cold.
DR. SARANG SURESH HOTCHANDANI 7

8. 6. Heat Test
• Using a ball of hot gutta percha on the tip of a plastic
instrument, place the gutta percha onto the tooth the same
way you would the ice. Wait approximately 15 seconds
between teeth to assess the possibility of a delayed, but,
prolonged response.
• Compare the results from other tested teeth. If one tooth
gives a prolonged response, whether immediate or delayed,
it is a most suspicious candidate for endodontics. If the pain
is immediately relieved by cold, the tooth probably needs
root canal.
DR. SARANG SURESH HOTCHANDANI 8

9. 7. Electric Pulp Test
• This test should be used when the hot and cold tests
fail to give clear information on the state of vitality
of the tooth. Again, the information supplied by the
electric pulp test must be weighed against the
response from other teeth. the fact that a tooth does
not respond to the EPT has little meaning if all the
other teeth also do not respond, unless of course
this is the only tooth with a well-defined area at the
apex or is quite tender to percussion.
DR. SARANG SURESH HOTCHANDANI 9

10. 8. Bite Sticks
• Use bit sticks to check for incipient fractures that are causing pain to a
tooth when under function. By having a patient bite on each cusp and
laterally move the lower jaw, each cusp is subjected to lateral stresses.
If a section of the tooth under a cusp has an incipient fracture it will
often hurt when pressure is applied.
• If a fracture does exist, the tooth may not need endodontics if the
fracture does not extend into the pulp. The pain generally disappears if
the fractured portion of the tooth can be cleaved off.
DR. SARANG SURESH HOTCHANDANI 10

11. 9. Trans illumination
• Trans illumination often confirms the portion of the tooth that has
the fracture. By placing the trans illumination light source on the
lingual side of the tooth and turning out the chairside light source,
fractures may be picked up as a dark horizontal line against a light
amber background. Trans illumination can sometimes differentiate
between vital and non-vital teeth with the non-vital appearing
duller than the surrounding ones when the light source is applied.
DR. SARANG SURESH HOTCHANDANI 11

12. 9. Trans illumination
• Trans illumination often confirms the portion of the tooth that has
the fracture. By placing the trans illumination light source on the
lingual side of the tooth and turning out the chairside light source,
fractures may be picked up as a dark horizontal line against a light
amber background. Trans illumination can sometimes differentiate
between vital and non-vital teeth with the non-vital appearing
duller than the surrounding ones when the light source is applied.
DR. SARANG SURESH HOTCHANDANI 12

13. 10. Binocular Microscope
•It is excellent for picking up incipient
fractures simply because you can look
at teeth magnified up to 30 X with
excellent illumination.
DR. SARANG SURESH HOTCHANDANI 13

14. 11. Selective Anesthesia
•It should be applied with an intraligamentary
gun. If specific anesthesia to one tooth makes
all pain disappear for a short time and the
effect is repeatable, the anesthetized tooth is
probably endodontically involved.
DR. SARANG SURESH HOTCHANDANI 14

15. 12. Drill Test Cavity
•If you believe that a non-vital tooth is causing
symptoms, but cannot confirm non-vitality with
assuredness, a test cavity without anesthesia
may allow entry into the pulp without any pain,
thus confirming your suspicions.
DR. SARANG SURESH HOTCHANDANI 15

16. THE END
DR. SARANG SURESH HOTCHANDANI 16