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Contemporary Endodontic Evaluationand Diagnosis: Implications forEvidence-Based Endodontic CareA Peer-Reviewed PublicationWritten by Manish Garala, BDS, MS

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Educational ObjectivesThe overall goal of this article is to provide the reader witha contemporary, evidence-based perspective on endodonticdiagnosis. Upon completion of this course, the reader will beable to do the following:1. List and describe the considerations in determining a

patient's chief complaint and the importance of obtainingan accurate dental history

2. List and describe the implications of pulpal exposure andthe success rates of direct pulp therapy

3. List and describe the tests that should be performed toassess the status ofthe pulpal and periradicular health

4. List and describe the types of cracked teeth, testing thatcan be performed and the implications for treatment

AbstractEndodontics has evolved as a truly scientific procedure and, whencorrectly diagnosed and performed, its research-reinforced statis-tics corroborate its high success rates. In order for a correct diag-nosis to be made, a number of steps and tests are required. Theseinclude ascertaining the source of the patient's chief complaint,understanding the patient's dental history and performing pulptests that are integral to the diagnosis. In addition, the possibilityof cracked teeth and periodontal involvement must be consideredand assessed during the diagnostic phase. Only after a complete ex-amination has been performed and a definitive diagnosis obtainedis it possible to create a treatment plan for successful endodontictreatment.

IntroductionEndodontics remains a cornerstone in the foundation fordental restorative care in the 21st century. Without success-ful endodontics, we are unable to provide many patientswith two of their most important facets - their ability tosmile while displaying their natural teeth and their abilityto use their natural teeth to eat with pain-free function. Arecent study by the American Association of Endodontistshighlighted this, with a third of participants stating that theywould not sell their front teeth for any amount of money.'Endodontics has evolved as a truly scientific procedure,and when correctly diagnosed and performed, its research-reinforced statistics corroborate its high success rates.• ' Thisis ultimately reflected by the high patient satisfaction withthe procedure. Eighty-five percent of patients who have hadendodontic treatment performed by an endodontist wouldreturn to him or her for future work. This serves to reinforcethe concept that endodontic procedures are valuable treat-ment modalities for the person who we ultimately serve, thepatient.

There are many myths and misconceptions in end-odontics, and many of these have been addressed by theresurgence in endodontic research. This article provides thereader with a contemporary, evidence-based perspective onendodontic diagnosis that will enable clinicians to be secure

and confident in the knowledge that they are striving toprovide quality endodontic care that follows guidelines andprinciples established from the latest endodontic research.

Endodontic DiagnosisTo perform successful endodontic treatment, it is first nec-essary to correctly diagnose the affected tooth or teeth. Thisdiagnosis can often be simple where there is a large cariouscavity and there are healthy, restoration-free adjacent teeth(Figure 1), or it can be extremely complex where the symp-toms are less defined and there have been multiple endodonticprocedures on numerous teeth (Figure 2). Irrespective ofthedetails ofthe case, the same protocol of examination and test-ing should be employed in each instance in order to obtainthe most precise response and establish an accurate diagnosis.

Figure 1. Periapkal radiograph displaying a large carious cavity ontooth #3

This was identified as the symptomatic tooth by pulp testing. The adjacentteeth have no restorations, and there is no perj-radicular pathology evidentwith them.

Figure 2. Periapical radiograph with existing RCT of satisfactory techni-cal status on teeth #2, #3 and #4, and coronal restorations

The Patient's Chief ComplaintAn examination should always be initiated by obtaining thepatient's chief complaint. This is critical, as it will provide in-formation as to what symptoms or pathology our subsequent

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tests will be searching for. Otherwise, a patient may be re-ferred or endodontic treatment performed on a non-offendingtooth because this critical step was overlooked. In the caseshown in Figure .3, the patient's chief complaint was painwith cold liquids. If this information had not been obtained, itwould have been correct to perform endodontic treatment ontooth #19 due to the presence of a large carious lesion, a pulpexposure and the peri-radicular pathology present. However,this would not have alleviated the cold-sensitivity symptom.Such treatment is likely to create an unhappy patient. Diag-nosis is typically more complex in this situation than for thecase in Figure 1.

Figure 3. Two pre-operative radiographs from different horizontalangulations

Note the significant radiographie caries in tooth #19 that has extended intothe pulp chamber, and the presence of a small peri-radicular radiolucency atthe apex of the mesial root. There is also an associated furcation radiolucency.Tooth #21 has a distal occlusal cavity that does not appear to have penetratedradiographically into the pulp chamber. There is peri-radicular widening ofthe periodontal ligament space.

I he greatest practice builder or opportunity to gain a pa-tient's trust is to alleviate his or her dental pain. Accuratehistory taking and proper diagnosis confirmed that the toothrequiring treatment was actually tooth #21 (Figure 4). Theconfidence that this creates with patients is important for theiracceptance of comprehensive dental care. It wtll still be neces-sary to treat tooth #19 due to its extensive caries, non-vitalityand apical pathology, but this is not the primary source of thei^atient's concern at this time.

Figure 4. Post-operative radiograph following endodontictreatment on tooth #21

Tooth #21 was displaying symptoms to cold, consistent with the patient'schief complaint. Tooth #19 remained asymptomatic despite the pathologypresent and was subsequently treated endodontically.

The Patient's Previous Dental HistoryUnderstanding previous dental history is a critical step whenobtaining information related to the chief complaint. It isimportant to determine whether a patient has had any recentdental treatment in the area where he or she is experiencingdiscomfort.

It is not unusual for patients who have had a scaling androot planing procedure to experience cold sensitivity due toexposure of dentinal tubules following calculus or cemen-tum removal.' For these patients, the discomfort related tocold stimuli should be immediate but also relieved withoutintervention within a few seconds. This type of sensitivity isreversible pulpitis and requires no endodontic treatment atthe time. For management of these symptoms, a desensitiz-ing agent (for example. Gluma) can be placed on the exposedsensitive surfaces. Gluma will cause the precipitation ofplasma proteins from within the dentinal fluid to obstruct thetubules, thereby decreasing the fluid flow and dentin perme-ability." Patients should also be instructed to use a desensi-tizing dentifrice, such as Sensodyne or Crest Sensitive, thatcontains potassium nitrate for nerve ending desensitization.The presence of potassium oxalate in desensitizing productsstimulates precipitate formation of potassium oxalate crys-tals, which further occlude the dentinal tubules.'^ In mostinstances, these palliative measures will control the patient'sdiscomfort and assist resolution of the symptoms. Shouldthe patient's symptoms persist beyond a period of two weekswithout any improvement, it may then be necessary to pro-vide endodontic treatment to remove the pulp, thereby elimi-nating the tooth's reaction to the external stimulus. There arevery few guarantees in clinical dentistry, but the eliminationof cold pain once the pulp tissue has been properly retnovedfrom the pulp chamber and all the canals is one of these. Thisis an example of interceptive endodontic treatment and isnecessary if the patient's symptoms cannot be managed bymore conservative methods.

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The placement of new filling restorations or crown/bridgeabutment preparations also needs to be identified as partof the dental history. It is inevitable that any form of toothreduction by caries formation, caries removal or mechanicalpreparation causes injury to the pulp.'' The pulp's capacityto repair is dependent on two factors: the extent of the injuryand the existing pulpal health.' The closer the restoration isplaced to the pulp the greater the reduction in residual dentinthickness, and the greater the injury the pulp will experience.'*Based on the results of studies, it is generally accepted thatthe effects of pulpal insults, whether due to caries, restorativeprocedures or trauma, are cumulative and that with eachsucceeding irritation the pulp has a diminished capacity forrepair and for remaining vital.

Figure 5a. Pre-operative radiograph highlighting the extensive canalspace calcification in tooth #8 in comparison to tooth #9

It appears that the ptjip attempted to heal by calcification of the canal spacebut was unsuccessful due to the deveiopment of symptoms.

Figure 5b. Post-operative radiograph

This radiograph demonstrates the ideal technical result that can he achievedviiith the use of high-power magnification to locate the canal and the conser-vative removal of the overlying canal calcification.

The pulp tissue s potential for repair is dependent on thepresence of an adequate microcirculation within the pulp tis-sue and the absence of extensive pulpal calcifications (whichare regarded as existing repairs of the pulp by scar formation)(Figure 5). The pulp in a young patient will have a greater ca-pacity to repair than it will in an older adult patient, as it has

probably experienced fewer insults. Therefore, in the absenceof acute, spontaneous and irreversible symptoms, youngerpatients should be given more time for the pulp to attemptrepair and for spontaneous resolution of symptoms.

Types of restorations associated with irrevers-ible pulpal damageStudies have shown that crown/bridge abutment prepara-tions produce some of the most damaging effects on the pulp.In one study, 16%of pulps became non-vital within a 10-yearobservation period, and 32% of previously confirmed vitalpulps became necrotic following bridge abutment prepara-tions. Anterior abutment preparations resulted in pulpnecrosis in over 50% of teeth examined in the study.'' Previ-ous studies found that pulp necrosis occurred 10-18% of thetime following crown preparations on vital teeth.'" Patientsshould be forewarned of the possibility of endodontic treat-ment being required following extensive crown/abutmentpreparations.

Pulp ExposurePulp exposure durmg caries removal creates significantpulpal inflammation, especially since the pulp has alreadybeen chronically inflamed by the advancing proximity ofthe carious lesion to the pulp. Although it may be possibleto provide some temporary relief from pulpal symptoms byperforming a direct pulp capping procedure, it is inevitablein adult teeth with complete root formation that the pulpwill eventually become necrotic and require endodontictreatment. The time frame for this to occur depends on theamount of existing pulpal inflammation and repair caused byprevious insults, and the size of the pulp exposure." Smallcarious pulp exposures (less than 1 mm' after complete car-ies removal) have a success rate of only 37% over five yearsand 13% over 10 years. When the exposures occurred, theywere treated in controlled clinical conditions under rubberdam isolation and pulp capped using a hard-setting calciumhydroxide paste with a glass ionomer or zinc phosphate base.All the teeth that demonstrated success developed significantcalcification of the pulp space (which is likely to make theendodontic procedure more challenging if the pulp cappingprocedure does eventually fail)."

A mechanical pulp exposure during restoration prepara-tion is different than a carious exposure. With the former,there tends to be limited existing pulpal inflammation priorto the exposure, tertiary dentin has not been laid down andthere has not been an immunologie response to an advancingcarious lesion. Furthermore, the exposure usually occurs inan environment that is relatively free of bacteria, which is indirect contrast to a carious exposure.

If it is decided that endodontic treatment is to be deferredat this time, and repair of the pulp exposure is to be per-formed, it should be considered that acid etching of dentinin close proximity to the pulp can cause severe chemical ir-

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ritation of the pulp. This is significantly worse when the pulpis exposed, as recommended in the total etch technique forexposure repairs.''

Ideally, repair of the exposure site should be carried outunder rubber dam isolation to prevent contamination of theexposure site, and the site should be closed using a hard-setting calcium hydroxide-based material or mineral trioxideaggregate (MTA, Dentsply, Tulsa OK) to prevent bacterialleakage and stimulate dentin bridge formation. The tooth willrequire monitoring, prior to permanent restoration place-ment, for sighs of irreversible pulpitis development in orderto ensure that the pulp has undergone the necessary healing.It may take 6-8 weeks until this can be confirmed by pulptesting and evaluation of symptoms. If the pulpal status is indoubt after this period of time, endodontics should be per-formed. This will eliminate the need to access the pulp cham-ber through the crown and potentially increase complicationswith canal location. It will also avoid the risk of fracture of anew crown.

Minimizing pulpal damageMinimizing pulpal responses is achieved by using adequatewater spray and coolant to prevent overheating or burning ofthe pulp. The use of a high-speed instrument that minimizespressure on the pulp also decreases the risk of these unde-sired effects." When using an etching technique in cavitieswith minimal remaining dentin, care should be applied toprotect the dentin from prolonged exposure to these strongacids. Dentin demonstrates significant permeability throughits dentinal tubules, and this can cause further injury to thepulp, as the unpolymerized monomer also has the ability toleach directly into the pulp through the dentinal tubules.'*Polymerization shrinkage and microbial leakage are principalcauses of pulpal irritation, as the shrinkage enables bacte-rial contamination of dentin in close proximity to the pulp.In these instances the effect can be compounded when thereis a reduced amount of protective dentin present to protectthe pulp.'' Further bacterial protection can be provided byusing a base below bonded restorations, providing an addi-tional layer for microbes present through leakage to overcomebefore they reach the inner layers of dentin and the pulp.Furthermore, the use of a calcium hydroxide base in verydeep cavities will also prevent the cytotoxicity of restorativematerials inhibiting the formation of tertiary dentin."' Theformation of tertiary dentin is critical for pulp repciir follow-ing cavity preparation.

Pulp TestingIrrespective of the dental history or the chief complaint, it isabsolutely essential that pulp testing be performed before thedecision is made to initiate endodontic treatment. If a patientis experiencing severe pain, and the offending tooth appearsobvious, it is still judicious to test the surrounding teeth to en-sure that they are not also affected or exacerbating the symp-

toms. It is disconcerting to hear from a patient the day afterendodontic treatment has been provided that the discomforthas persisted in a manner identical to that experienced beforetreatment. This can be avoided by first ascertaining that thecorrect tooth has been identified as having the endodonticproblem or that the surrounding teeth were affected as well.Although it is unlikely that two teeth are affected to the sameextent or that they will display similar symptoms at the sametime, this could well be true for quadrants or arches wherepreparations have been performed simultaneously.

Pulp testing should be carried out systematically and inan organized manner, enabling information that is obtainedto be compared with that of the different teeth that are tested.An example of such an approach would be to perform thesame test sequentially on all the teeth in the same sextant.The same tooth on the contralateral side could be used as areference, and this is typically carried out for anterior teeth.Ideally, the opposing arch sextant should also be tested as partof the diagnostic process. This is mandatory when the patientis complaining of pain that refers between arches, irrespjectiveof whether this pain has now localized. This methodical ap-proach prevents the wrong tooth from being diagnosed as theculprit, and it also reassures the patient that there are no otherteeth that could be stimulating the painful symptoms. At aminimum, the suspect tooth and the two teeth on either sideof it should be tested. This will enable useful comparisons tobe made among the responses obtained, which will assist inthe development of a diagnosis and the isolation of the of-fending tooth.

Series of tests to be performedThe essential tests are outlined in Table 1. These tests focuson determining the pulpal status and the peri-radicular statusof each tooth.

Table 1. Essential tests

DIAGNOSTIC TESTS / / Date:

Tooth #

Palpation

Mobility

Percussion

Bite/Chewing

Cold

Heat

EPT

Transillumina-tion

Perio Probings

Cavity Test

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The first test to be undertaken should not be the stimulusthat the patient feels is responsible for triggering his or herpresenting symptoms. It should also not be undertaken onthe tooth that is suspected to be the source of the symptoms,thereby preventing the initiation of pain that may or maynot subside quickly and consequently affect the results ofthe remaining tests.

Palpation TestsThe first series of tests serve to determine the peri-radicularstatus. Palpation tests are performed using firm pressurefrom an index finger on the buccal and lingual mucosa inthe area of the root apex and then on the gingival margin ofeach tooth to be tested. This palpation will help to identifywhether there is swelling present at the apex of these teeth orif there is severe apical inflammation. If present, the natureof the swelling should be identified to formulate a treatmentplan for management, which could include no treatment,incision and drainage with or without an indwelling drainleft in place, or trephination. Palpation testing around thegingival margin will help to determine whether purulentdrainage through the buccal sulcus is present, providinginformation about the infection status of the peri-radiculartissues.

Identification of sinus tracts should also be per-formed at this time. The correct definition of a drainagepoint on the mucosa emanating from the peri radiculartissue precludes the use of the word "fistula," since thisis defined as an opening between two epithelium-linedcavities or organs." This term is more appropriate foran opening created surgically between the sinuses andthe oral cavity, which can happen during extraction ofmaxillary molars.

Mobility TestThe second test performed is a mobility test to determinetooth stability. Buccal to lingual movement of the tooth us-ing a mirror handle and the index finger, or using the thumband index finger, can help determine the amount of toothmobility. This is rated on a scale of 1 to 3, with a grade 1representing 1 mm of buccal to lingual movement, grade2 representing 2 mm of buccal to lingual movement, andgrade 3 being depressible by greater than 1 mm and withgreater than 2 mm of buccal to lingual movement. If thereis grade 2 or 3 mobility, it could be the result of a numberof factors, including trauma, rapid orthodontic movement,root fractures or, most commonly, periodontal disease.Periodontal disease present would have to be confirmed bya periodontal examination and may or may not be relatedto endodontic etiology. This mobility should significantlyimprove following endodontic treatment if it is related topulpal non-vitality. This test can also be valuable as it mayelicit symptoms if there is significant periodontal ligamentinflammation of the affected tooth.

Bite TestThe third test is usually a bite test. This is typically performedusing a cotton-tipped applicator. Patients are instructed toclose their teeth together on the end of the applicator, whichis placed in the central area of the tooth to be tested (Figure6). If any pain is elicited, patients should be asked to confirmwhether this pain is upper or lower before they release thepressure from the applicator. Patients should next be askedto grind from side to side on the applicator to determinewhether lateral movements invoke a painful response. Fol-lowing release of biting pressure on the applicator, patientsshould be questioned as to whether there was any pain uponrelease of the applicator. This is important in the detectionof cracked teeth, which will be discussed later in the article.These bite tests help isolate the offending tooth if a patientis complaining of biting pain, and assist in the peri-radiculardiagnosis of the tooth.

Figure 6. Bite stick test

This test is conducted to confirm the presence or absence of symptoms to bitingpressure or chewing. The patient is asked to close on a cotton-tipped applicatorthat is placed between the occlusal surfaces of two opposing teeth. The presenceor absence of a painful response is determined for each tooth that is tested.

Percussion TestPercussion is another test used to isolate the causative toothand helps in determining the peri-radicular diagnosis. Thistest is typically performed using the metal handle end of anintra-oral mirror, and the tooth is gently tapped a few timesfrom the occlusal and then the buccal surface. The intensityshould be minimal but repeated consecutively, with eachtapping motion becoming slightly more pronounced. Apainful response confirms the presence of peri-radicularinflammation, and the intensity of the discomfort can becompared with other teeth by the increase in severity of thesymptoms when the tooth is repeatedly percussed as de-scribed. It is not unusual for teeth adjacent to the symptom-atic tooth to be sensitive also, but this is unlikely to increasein intensity in a manner similar to the problematic tooth andcan usually be distinguished from the causative pain basedon the non-progression in intensity of the pain response withrepeated gentle tapping. If the discomfort does not progress

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with repeated percussion, this would be termed a sensitivetooth that should be re-evaluated at the next appointmentto determine if these symptoms have dissipated, since theacute symptoms from the tooth that was treated should haveresolved by then.

Pulp Vitality TestsThe next series of tests are collectively termed pulp vitality

tests and are performed in order to determine the pulpal sta-tus. These tests are important, as there has to be irreversiblepulpal inflammation present for peri-radicular inflammationto be initiated by endodontic etiology. Thermal testing is themost accurate method of testing pulp vitality and is carriedout to stimulate A-delta fibers in the pulp. These fibers aresome of the most resistant to degeneration, and the absenceof sensations during testing is a true indicator of irreversiblepulp damage, which is the precursor to pulp necrosis.

Cold TestingCold testing causes contraction of dentinal fluid within thetubules, with a subsequent rapid outflow of fluid in the tu-bules that stimulates mechanoreceptors in the pulp-dentincomplex, resulting in a sharp instantaneous response. In atooth with a healthy pulp, this will typically fade within a fewseconds of the stimulus being removed. When the pulp hasbecome irreversibly inflamed, the cold stimulus will usuallyinitiate a lingering, exaggerated response for seconds, if notminutes, after the cold stimulus has been removed. This mayradiate to the adjacent teeth or those in the opposite arch.The other non-normal response is the lack of a reaction tocold despite testing on both buccal and lingual surfaces ofthetooth. Testing is carried out using a variety of cold materials,each with varying degrees of coldness. The material used isselected based on the patient's chief complaint. If he or she iscomplaining of pain from cold even when breathing in coldair, then it is inhumane to use an Endo Ice spray that willsend his or her pain levels soaring. It is more appropriateto use cold air from the air/water syringe to directly sprayair to the buccal gingival margin of each tooth individually,while the other teeth are completely shielded using dry gauze(F'igure 7). The cold air may not be sufficiently cold to evokeresponses in all teeth that have healthy pulps, but the offend-ing tooth should be easily detected using this method. Thismethod has numerous limitations and should be used onlywhen a patient cannot tolerate anything that is remotely coldin his or her mouth.

Patients who provide information that cold drinks or icestimulates their pain should be tested using ice pencils. Thesecan be made at little or no cost by freezing water in local an-esthetic needle sheaths that have not been contaminated. Oneend is covered with gauze to provide a handle while the exposedend is applied to the tooth. A lingering response to cold, oracute pain to cold that is exaggerated compared to the pain ofthe surrounding teeth and similar to the patient's symptoms

when he or she drinks, is a good indicator that the causativetooth has been loccJized. It is important that the other teeth re-main isolated, to prevent the ice pencil from melting and watercontacting the adjacent teeth. This test has significant limita-tions, as the pencil can melt and contact the adjacent teeth, orwater can drip down from the pencil when testing upper teethand contact the lower teeth.

Figure 7. Application of a fine air spray of cold air from a Stropko Irrigator

The fine air spray is directed toward the buccal gingival margin ofthe toothto be tested and in the direction of the region already tested. Teeth #6 and#7 have already been tested, and the teeth posterior to tooth #5 are wellshielded from the air spray by the tight adaptation of dental gauze (2"x2")to the posterior teeth.

Patients who complain of intermittent pain, constant painor pain that is indiscriminate, without definitive painful re-sponses to cold, are tested using very cold substances such as1,1,1,2-tetrafluoroethane (e.g., Endo Ice, Hygienic, Akron,OH) (Figure 8).

Figure 8a. Endo Ice canister

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This has a temperature of -37 °F and can even evoke re-sponses from the pulp underneath porcelain fused to metalcrowns and gold crowns. This should be the primary mode ofcold testing during the diagnostic phase of treatment, whenthe situations described above are not present. The solutionIS sprayed onto a cotton pellet until it is saturated. This is thenapplied to the buccal surface of the tooth at least 3-4 mm abovethe gingival margin. The pellet is held to the tooth for 5-10seconds or until the patient obtains a response (Figure 8c).

Figure 8b. Cotton pellet immediately after saturation with Endo Ice

Figure 8c. Application cf thcíí3 cotton pellet "h Endo Ice

This is applied to the buccal surface of tooth #28, away from tooth #27 ortooth #29, maintained in contact with the tooth for 10-15 seconds, andthe presence or absence of a response confirmed.

The absence of a response to cold testing by this method,when correctly performed, is a likely indicator of pulp necro-sis. A second test should be used to confirm this diagnosis.It should be determined whether this response is lingering,delayed, more intense, less intense or similar to the other teeththat have been tested. Whenever there are lingering or acutesymptoms with cold testing, a diagnosis of irreversible pul-pitis is made. It has been determined from controlled clinicaltrials that it is not necessary to place the patient on antibioticssuch as penicillin, as this will not improve their symptoms.'"It is more beneficial to remove the diseased pulp from thetooth as expediently as possible.

Heat TestingThe application of heat is usually reserved for cases where thepatient states that he or she is experiencing pain with warmsubstances. The pain in these situations is usually intense andlingers for a period of time following the intake of the warmsubstance and its stimulation of the offending tooth. It is not un-usual for patients with severe discomfort to be constantly bath-ing the tooth in cold water to prevent the pain from escalating.

The application of heat causes expansion of the gasescreated by necrosis to invoke significant pain. Pain with heatis typically an indicator of partial pulp necrosis and the ini-tiation of a pulpal infection in the tooth. When patients areexperiencing pain with heat, this test should be used as oneof the final tests, after other testing has been performed andadditional information has been obtained. Even if prior test-ing provides a definite diagnosis as to the affected tooth, theheat test should still be performed to reassure the patient andthe treating doctor that the etiology will definitely be man-aged by endodontic treatment. Application of heat stimulatesa response in the pulp by causing expansion of the fluid insidethe dentinal tubules. This movement will again trigger the A-delta fibers located around the tubules. Once the symptomshave been reproduced, cold can be quickly reapplied to thetooth using Endo Ice spray or applying an ice pencil to thebuccal surface, and this should again relieve the patient'sdiscomfort. It is possible, especially in patients with restora-tions in numerous teeth, that there may be more than onetooth with potential endodontic involvement, flowever, it isimportant to remain focused on the tooth that is creating thechief complaint for the patient, whose expectation is that thesymptoms will be resolved by the endodontic treatment he orshe is about to undergo.

Electric Pulp TestThe final test that is used for pulpal diagnosis is the electricpulp test (Figure 9). This test will stimulate the A-delta fibersthat are also stimulated by thermal testing. A metal hook orclip is placed on the patient's lip, and a probe tip covered in aconducting medium such as toothpaste is applied to the mid-dle third of the tooth surface. Whenever possible, the probeshould not contact the surface of a restoration. A pulsatingelectric stimulus is created, beginning at a very low value andgradually increasing in intensity. When patients experience apulsing, tingling or vibrating sensation, they are instructedto indicate their response to the stimulus. The probe is thenremoved and the next tooth tested. It is prudent to test anadjacent or contralateral tooth before the suspected tooth sothat the patient has some awareness of the responses he or sheis supposed to feel. This test will confirm the presence of vitalpulp tissue but should be used only as an adjunct for pulpaldiagnosis. This is because there is a risk of false positive re-sponses where the A-delta fibers have become non-vital butthere is still a positive response from the tooth. This can occurfrom the periodontal tissues, from inadequately dried teethand from contact with metallic restorations. In conjunc-tion with the pulp testing performed, it is also important toestablish etiology for the symptoms and pulpal responses. Itis straightforward to establish this in cases where there arelarge cavities or restorations in close proximity to the pulp, orwhere crown preparation work has been recently performed,but there appears to be a greater incidence of cracked teeth,which could also be the etiology for a patient's symptoms.

October 2010 www.dentaleconomics.com

Figure 9. Application of the electric pulp tester to the mid-buccal

surface of tooth #8 for vitality testing

The patient is holding the sensor ds ilie operator is wearing gloves (as recom-mended), and there is a conducting medium (toothpaste) on the tip of thesensor to provide good electrical contact.

Cavity Test"(Cavity test" refers to access, without anesthesia, to a cavitypreparation in a tooth that is suspected to be necrotic. Thisis rarely necessary when all other tests are performed, and itshould be reserved only for very unusual situations.

Cracked TeethCracked teeth complicate diagnosis, as the symptoms are of-ten vague, intermittent, and difficult to isolate or reproduce.Bite tests may elicit the pain that the patient is experiencing,but the pulp can rapidly become non-vital when the toothhas cracked and the cracks have entered the pulp chamber.This can result in the rapid loss of symptoms, thereby mak-ing tbe offending tooth difficult to diagnose until furthersymptoms or pathology manifest. To understand the testingrequired when determining the presence of a cracked tooth, itis first necessary to differentiate between the different typesof cracks that may be present in the tooth.

Cracked CuspsIhe first potentially symptomatic situation is the presence of

a cracked cusp, where the cusp on a posterior tooth is crackedat the base on the pulp chamber floor. This may or may notproduce pulpal symptoms such as temperature sensitivity,but there should be biting discomfort when pressure is ap-plied to the affected cusp. Testing should also be carried outon the other cusps to confirm that it is just a cracked cuspsituation and that the tooth as a whole has not cracked. Whenthere is a suspicion ofa cracked cusp, the existing restorationshould be removed and méthylène blue applied to the pulpchamber floor and the potentially affected cusp. The méthy-lène blue should then be rinsed away within 10-15 seconds,but it will remain in the crack and be easily identifiable usingmagnification (Figure 10).

Application of firm outward pressure to the cusp from theinternal aspect of the cavity often results in the cusp becomingdislodged from the tooth at its base. If the pulp is not exposed

by loss of the cracked cusp, a restoration may then be placed,with no need for endodontic treatment, unless the tooth be-comes pulpally symptomatic following crown preparationand temporary restoration placement.

Figure 10. Examination of tooth using dental microscope (Zeiss OPMI

pico, Zeiss Méditée, Dublin, CA) for 16x magnification

Existing filling removed and méthylène blue used to stain internal surfacesof occlusal cavity. Staining reveals a crack on mesial marginal ridge and ahorizontal crack on buccal wall, extending mesial to distal.

Cracks on the Pulp Chamber FloorThe second potentially symptomatic cracked tooth situa-tion is when the crack has extended from the mesial and/ordistal walls onto the pulp chamber roof. A crack on the pulpchamber roof will likely induce pain with pressure that ischaracterized by a sharp pain on release of pressure when bit-ing. As in cracked cusp situations, pulpal symptoms may ormay not be present. Symptoms to pressure may be difficult toelicit unless the cracked area is compressed. Once symptomshave been identified, a transillumination device can be usedto confirm the presence of cracks underneath any restorationsthat may be present and to determine the extent and depthof the cracks. This is usually confirmed by shining a brightlight on the buccal or lingual surface of the tooth. For a tooththat is not cracked, the light will shine through to the oppositesurface without any interruption.

Figure 11. Use of a transillumination device

Cracks were detected on the occlusal surface during the examination. The mesialhuccal cusp is fractured, as the light does not extend through this cusp toward thedistal or lingual surface. An additional crack line can also be seen on the mesialmarginal ridge.

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The presence of a crack underneath the occlusal surfacewill inhibit the passage of light through the tooth (Figure 11).This provides additional confirmation that the tooth has in-deed cracked and interventional treatment is necessary. Themost commonly cracked teeth are mandibular molars andthen maxillary premolars, followed by maxillary molars."'•^°

Periodontal ExaminationThe decision to treat a cracked tooth or any endodonticallyinvolved tooth should not take place without a thoroughperiodontal examination to determine the status of the sup-porting tissues. Six measurements are taken for periodontalpocket depths around the tooth. This is important, as thepresence of deep periodontal pocketing adjacent to a rootsurface can be indicative of a vertical root fracture that isprogressing apically and simultaneously compromising theperiodontal attachment. The pocket in these instances istypically narrow and affects only one probing location un-less the problem has been long standing and has caused morewidespread periodontal destruction. It is always helpful toplace a small gutta-percha (GP) cone in the pocket and tracethe pocket depth radiographically (Figure 12).

Figure 12a. Tooth #19 is tilted mesially and has an existing RCT andcrown that radiographically appear technically satisfactory

There is a radiolucency in the furcation and at the distal alveolar creston the distal surface of the distal root. There is a small peri-radicularradiolucency limited to the distal root apex, but there is circumferentialthickening of the periodontal ligament space around the distal root.

Figure 12b. Radiographic periodontal pocket confirmation

Mid-buccal and distal buccal 9-10 mm pockets traced using GP points toconfirm pocket depth and location.

This will provide a visual representation of the depthof the pocket and may also assist with determining theetiology. If the GP cone traces to the coronal or mid-rootregion of the root and there is no associated periapicalradiolucency, it is likely that the etiology is a root fracture.When the tooth is responding positively to pulp vitalitytesting, the periodontal pocket is unrelated to the pulpalstatus, as a positively responding pulp cannot have aninfection that is significant enough to stimulate a peri-odontal infection. In these instances it is more likely thatthe etiology is periodontal or fracture related. A referralto a periodontist for further evaluation may be necessarybefore the etiology can be confirmed and a definitivetreatment plan formulated. Periodontal pocket formationcan also be from the development of pulpal non-vitality,secondary to an internal crack and the subsequent estab-lishment of a drainage path through the periodontal sup-port.

When a deep periodontal pocket is associated witha non-vital tooth, there is the likelihood that the peri-odontal pocket will resolve once endodontic treatmentis performed. The pocket should again be traced prior totreatment using a small GP cone to provide a record ofthe pocket depth. Endodontic treatment should then beinitiated, and the absence of fractures extending into theroot canals or across the pulp chamber floor should beconfirmed visually, ideally under magnification.

The pocket depth should be re-evaluated once suf-ficient time has elapsed for periodontal healing, whichis typically 6-8 weeks.-' Confirmation of a primaryendodontic problem with secondary periodontal break-down is confirmed by periodontal pocket resolution.Should the pocket persist, referral to a periodontistwould be necessary for possible pocket debridement orexploratory flap surgery to determine the etiology fornon-healing.

Sinus TractsThe development of a sinus tract is similar to the estab-lishment of a periodontal pocket, with the difference thatthe sinus tract can appear on any part of the surround-ing soft tissues. A sinus tract can occur irrespective ofthe presence of a crack and is defined as the formationof an opening on the soft-tissue surface for the body toestablish drainage of infection. For it to be of endodonticorigin, the pulp must be non-vital, and usually there isan associated peri-radicular radiolucency radiographi-cally. These tracts should always be traced to determinethe origin of the infection. Not only does this providedefinitive confirmation as to the causative tooth, it willalso help to determine the presence of unusual anatomy.It is not uncommon to see a sinus tract tracing to the lat-eral aspect of the tooth when there is a large lateral canalpresent (Figure 13).

October 2010 | www.dentaleconomics.com

Figure 13a. Diagnostic tracing of a sinus tract

Tracing using a GP cone to the distal surface of tooth #4, wimnradiographically with a lateral, not a peri-radicular, radiolucency

Figure 13b. Immediate post-operative radiograph

Note the radio-opaque filling material within a large lateral canal adja-

cent to the lateral radiolucency.

Figure 13c. One-month recall radiograph

Note the almost complete resolution of the existing lateral mid-root radiolucency

following endodontic treatment.

SummaryCompilation of the information obtained from the results ofall tests enables accurate endodontic diagnosis and formula-tion of a treatment plan. As a result of this comprehensivetesting, the offending tooth should have been identifiedand a pulpal diagnosis made. The diagnosis determines thetreatment planning for the procedure to be performed, espe-cially when considering the extent of emergency treatmentto be provided, and will aid the formulation of a definitivetreatment plan that is in the best interest of the patient andthe clinician.

References1 American Association of Endodontists: Endodontic fact

sheet - endcxJontics and endcxiontists. 200.S. Available at www.rcxjtcanalspeciahsts.org.

2 Sahlerabi R, Rotsein I. Endcxiontic treatment outcomes in a largepatient population in the USA: an epidemiological study. J EndcxJ.2004;.«)(12):846-50.

3 Bergenholtz G, Lindhe J. Effect of experimentally induced marginalperiodontitis and periodontal scaling on the dental pulp. J C linPeriodontol. 1978;5:59.

4 Schüpbach P. Lutz F. et al. Closing of dentin tubules by C ilumadesensitizer. Eur J Oral Sei. 1997;105:414.

5 Pashley DH. Potential treatment modalities for dentin hyper-sensitivity in office products. Tooth Wear and Sensitivity. 2000,Martin-Dunitz, 351.

6 Brannstrom M, Lind PO. Pulpal response to early dental caries. JDent Res. 1965;44:1045.

7 Abou Rass M, The stressed pulp condition: An endodontic-restorative diagnostic concept. J Pros Dent. 1982:48:264-67.

8 Lee SJ. Walton RE. Osborne J W. Pulp response to bases and cavitydepths. Am J Dent 1992;5(2): 64-8.

9 Cheung GS. Lai SC, Ng RP. Eate of vital pulps beneath a metal-ceramic crown or a bridge retainer. Int EndodJ. 2OO.S;38:521-3O.

10 Eelton D. Long-term effects of crown preparation on pulp vitality. JDent Res. 1989;68:1009.

11 Barthel CB et al. Pulp capping of carious exposures: treatmentoutcome after 5 and 10 years: a retrospective study. J Endod.2000;26(9):525-28.

12 Pameijer CH, Stanley HR. The disastrous effects of the "total etch"technique in vital pulp capping in primates. Am J Dent. 1998; 11 :S45[published erratum appears in Am J Dent. t998;ll(3):148].

13 Stanley HR, Swerdlow H. An approach to biologic variation inhuman pulp studies. J Prosthet Dent. 1964:14:365.

14 Hume WR, GerziaTM. Bioavailability of components oí resin-based materials which are applied to teeth. Crit Rev Oral Biol Med.1996;7:172.

15 Bouillaguet S. Biological risks of resin-based materials to the dentin-pulpcomplex. Crit Rev Oral Biol Med. 20O4;l 5:47.

16 Murray PE. About I, et al. Restorative Pulpal and RepairResponses. J Am Dent Assoc. 2001:132: 482- 90.

17 Baumgartner JC, et al. Microscopic examination of oral sinus tractsand their asscKiated periapical lesions. J Endod. 1984; 10(4): 146.

18 NagleD, Reader A, Beck M, Weaver J. Effect of systemic penicillinon pain in untreated irreversible pulpitis. Oral Surg Oral Med OralPathol. 2000;90:636.

19 Cameron CE. The cracked tooth syndrome: additional findings. JAm Dent Assoc. 1976;93:971-75.

20 Homewood CL Cracked tooth syndrome: incidence, clinical find-ings andtreatment. Aust Dent J. 1998;43:217 22.

21 Scheyer ET. Personal communication on healing of pericxiontalpcKket from a primary endcxiontic etiology, following endcxiontictreatment. 2009.

Author ProfileManish Garala BDS, MS, Diplomate, American Board of Endodon-

tics is in specialist endodontic practice in Houston, and also adjunct

faculty in the department of Endodontics at UTDB Houston. He can be

reached by email at mg@ceendo.com.

DisclaimerThe author(s) of this course has/have no commercial ties with the spon-

sors or the providers of the unrestricted educational grant for this course.

Reader FeedbackWe encourage your comments on this or any PennWell course. For your

convenience, an online feedback form is available at www.ineedce.cotn.

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1. The same protocol of examination and testingshould be employed in eaeh instance in orderto obtain the most precise response andestablish .a. a differential diagnosisb. a tentative diagnosisc. the most accurate diagnosisd. none ofthe above2. An examination should always be initiated

y ^a. obtaining the patient's chief complaintb. obtaining all of the patient's complaintsc. pulp testingd. none ofthe above

3. Reversible pulpitis _a. can be related to recent scaling and root planing

proceduresb. results in pain that is immediate but also relieved

without intervention within a few secondsc. requires no endodontic treatment at the timed. all of the above

4. Any form of tooth reduction by cariesformation, earies removal or mechanicalpreparation .a. always results in the formation of secondary dentinb. results in abfractionc. causes injury to the pulpd. none ofthe above

5. T h e pulp's capacity to repair .

Questions

11. Palpation tests are performed .a. using firm pressure from an index finger on the buccal

and lingual mucosa in the area ofthe root apex of eachtooth to be tested

b. using firm pressure from an index finger on the gingivalmargin of each tooth to be tested

c. to help identify whether there is swelling present at theapex of these teeth or if there is severe apical inflamma-tion

d. all of the above

12. Identification of sinus tracts should beperformed at the time of .a. the bite testb. palpation testingc. periodontal examinationd. all ofthe above

13. A mobility test is performed to determine

a. tooth vitalityb. tooth stabilityc. the patient's level of paind. all ofthe above

14. Grade 2 or 3 mobility eould be the result of

a. depends on the extent ofthe injuryb. is dependent on the presence of an adequate

microcirculation within the pulp tissue and the absenceof extensive pulpal calcifications

c. is greater in younger patients than in older adult patientsd. all ofthe above

6. In the case of a mechanical pulp exposure

a. there tends to be lmiited existing pulpal inñammationprior to the exposure

b. tertiary dentin has not been laid downc. the exposure usually occurs in an environment that is

relatively free of bacteriad. all ofthe above

7. Pulpal responses, as a result of procedures,can be minimized by .a. adequate water sprayb. coolantc. high-speed instrumentsd. all of the above

8. Irrespeetive of the dental history or the ehiefcomplaint, it is absolutely essential that

be performed before the decision ismade to initiate endodontie treatment.a. pulp testingb. bite testingc. periodontal testingd. none ofthe above

9. Pulp testing should be earried out in anorganized, systematic manner, enablinginformation that is obtained .a. to be verified digitallyb. to be programmedc. to be compared with that ofthe different teeth that are

being testedd. none ofthe above

10. The first test to be undertaken should be thetest that for triggering his or herpresenting symptoms.a. the clinician feels is responsibleb. the patient feels is responsiblec. the radiograph indicates is responsibled. all of the above

a. trauma or root fracturesb. rapid orthodontic movementc. periodontal diseased. all ofthe above

15. Bite tes t s .a. are important for the detection of cracked teethb. are typically performed using a cotton-tipped applicatorc. help isolate the offending tooth if a patient is complain-

ing of biting paind. all of the above

16. A percussion test .3. is used to isolate the causative toothb. is typically performed using the metal handle end of an

ijitra-oral mirror, and the tooth is gently tapped a fewtimes from the occlusal and then the buccal surface

c. helps in determining the peri-radicular diagnosisd. all ofthe above

17. It is not unusual for teeth adjacent to thesymptomatie tooth to percussiontesting.a. to be sensitiveb. to be insensitivec. to be resistantd. none ofthe above

18. There has to b e . _ pulpal inflamma-tion present for peri-radieular inflammationto be initiated by endodontic etiology.a. reversibleb. irreversiblec. palpabled. none of the above

19. W h e n the pulp has become irreversiblyinflamed, .a. the cold stimulus will usually initiate a lingering,

exaggerated response for seconds, if not minutes, afterthe cold stimulus has been removed

b. pain may radiate to the adjacent teethc. the response (pain) may radiate to the teeth in the

opposite archd. all ofthe above

20. Patients who complain of intermittent orconstant pain, or pain that is indiscriminate,without definitive painful responses to cold, arete.sted using substances.a. lukewarmb. very hotc. very coldd. all of the above

2 1 . The absence of a response to cold testing,when correctly performed, .

a. is a likely indicator of pulp necrosisb. should be followed by a second test to confirm this

diagnosisc. is a likely indicator of pulpal healthd. aandb

22. Pain with heat is typically an indicator of

a. complete pulp necrosisb. partial pulp necrosisc. periodontal diseased. noneoftheabove

23. T h e final test that is used for pulpaldiagnosis is the .a. mobility testb. palpation testc. electric pulp testd. periodontal test

24. It is prudent when performing electric pulptests to .a. test an adjacent tooth before the suspected toothb. test a contralateral tooth before the suspected toothc. ignore adjacent teethd. a orb

25. Electric pulp testing .a. will confirm the presence of vital pulp tissueb. should be used only as an adjunct for pulpal diagnosisc. stimulates the A-delta fibersd. all of the above

26. A cracked cusp on a posterior looth that iscracked at the base on the pulp chamber lloor

a. may or may not produce pulpal symptoms such astemperature sensitivity

b. always produces pulpal symptoms such as temperaturesensitivity

c. should be associated with biting discomfort whenpressure is applied to the affected cusp

d. a orb

27. Méthylène blue is used to confirm thepresenee of _.a. dental canesb. a cracked cuspc. periodontal diseased. all ofthe above

28. T h e most eommonly cracked teeth are

a. mandibular molarsb. maxillary molarsc. maxillary premolarsd. none ofthe above

29. Periodontal pocketing adjacent to a rootsurface .a. can be indicativeof a vertical rootfractureb. can result from the development of pulpal non-vitality,

secondary to an internal crackc, will resolve following successful endodontic treatment

if related to a primary endodontic problem and theperiodontal breakdown was secondary to this

d, all ofthe above

30. Comprehensive testing dur ing endodontiediagnosis aids in formulating athat is in the best interest ofthe patient.a. tentative treatment planb. definitive treatment planc. three-stage treatment pland. none ofthe above

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