Diagnosis and Diagnostic aids in Endodontics

Introductiony Diagnosis is the correct determination, discriminitive

estimation and logical apraisal of conditions found during examination as evidenced by distinctive signs,marks and symptoms. y It is also defined as an art of distinguishing one disease from the another.

y As a correct treatment begins with a correct

diagnosis,So diagnostic procedures should follow consistent logical order which includes comprehensive medical and dental history,radiographic examination,extraoral and intraoral clinical examination including histopathological examination to arrive at final diagnosis. y Process begins with the initial call requesting appointment for some specific reason,usually a complaint of pain.

y Subjective symptom is supplied by the written history

or questionnaire that each patient completes and signs. y Further information is obtained by the clinician, who reviews the questionnaire and ask specific questions regarding the patient s chief complaint ,past medical history ,past dental history, present medical and dental status. y Clinician should consult to the patient s physician whenever patient appears to be medically compromised or when the gained information is inadequate or unclear.

Medical history is important because medical history affects the course of treatment,especially concerning the use of anaesthetics ,antibiotics and analgesics. y Occasionally a patients medical status bears a direct relation to the clinical diagnosis.For ex- Difffuse pain in the mandibular left molars may be a referred pain caused by angina pectoris, or Bizarre symptoms may be the result of psychogenic and neurologic disorders.y

History and Recordy Case history is defined as data concerning an individual and his or her family and environment,including the individual medical history that may be useful in analyzing and diagnosing his or her case or for instructional purposes. y As many disease has similar symptoms the clinician must be astute in determining the correct diagnosis. y Differential diagnosis is the most common procedure . This techique distinqishes one disease from several other similar disorders by identifying their differences. y On the other hand diagnosis by exclusion eliminates all possible disease under consideration until one remaining disease correctly explains patients symptoms.

Symptomsy Symptoms are the units of information sought in

clinical diagnosis. y Symptoms are defined as phenomena or signs of departure from normal and indicative of illness.Symptoms can be classified as follows: y Subjective symptoms: Those experienced and reported to the clinician by the patient. y Objective symptoms:those ascertained by the clinician through various tests.

Subjective symptomsy Completed medical form concerning the patient,s past

dental history consist of subjective symptoms. y Patient,s reason for seeing the dentist is subjective symptoms. Generally a chief complaint relates to pain, swelling and esthetics.

y PAIN: most common problem that leads to dental treatment Questions about pain should be asked such as: kind of pain, its location ,its duration ,what causes it,what allevates it whether its is referred to other side or not.. Generally pulpal pain is described in two ways by the patient. 1. Sharp,Piercing and lancinating type y 2.Dull, boring ,gnawing and excruciating type y After this the ability to localize the pain is also important . Whether the pain is localized or diffused.

y Pain is localized when the patient point to a specific

tooth or site with assurance and speed when asked to do. y Pain is diffused, when the patient describe an area of discomfort rather than a specific site. y When the patient is asked to to point to the most painful spot,patient,s finger move along the dental arch or between the maxilla and mandible. y Diffuseness is diagnostic because the inability to localize the pain frequently relates to dental pain that is dull,boring grawning,from a tooth that respond abnormally to heat more than to cold and with symptoms that can be referred to other sites.

y Duration: duration of pain is also diagnostic,as pulpal

pain lasts only as long as an irritant is present.At other times it may last minutes to hours. y Pain may either be intermittent or constant. y Clinical experience has shown that a tooth fleeting pulpal pain which disappear on removal of irritant has an excellent chance of recovery without the need of endodontic treatment. y Acute reversible pulpitis is characterized by pain of short duration,caused by a specific irritant which disappear as soon as the irritant is removed. Pain is usually localized and is more responsive to cold than heat.

y If the pain persist persists or if it occurs without any

apparent cause ,the pulpitis will usually be irrerversible and the patient will require endodontic therapy. y Spontaneous pain and pain of long duration indicated irreversible pulpitis. y Abnormal dental pain caused by heat usually requires endodontic treatment. y Pain that occurs on changing the position of head awakens the patient from sleep or occurs during mastication of food in a cariously exposed tooth usually indicate endodontic treatment.

Objective SymptomsObjective symptoms are performed by the tests and observations performed by the clinician . These test includes: 1) Visual and Tactile inspection 2) Percussion 3) Palpation 4) Mobility and depressibility 5) Bite test 6) Radiograph 7) Electric pulp Test 8) Thermal Tests( hot and cold) 9) Anaesthetic test 10) Test Cavity

Visual and Tactile Inspectiony Visual and tactile examination of hard and

soft tissues relies on checking : Color Contour Consistency In soft tissues such a gingiva deviation from the healthy pink color is recognized when inflammation is present,Change in contour occurs during swelling,Change in consistency from normal,healthy,firm tissue to soft,fluctuant and spongy tissue indicate a pathologic condition.

y Similarly teeth should be visually examined using the three Cs. such as Color

Contour Consistency COLOR: A normal appearing crown has a leaf-like translucency and sparkle that is missing in pulpless teeth. Teeth that are discolored, opaque and less leaf-like appearance should be carefully evaluated because the pulp may already be inflamed ,degenerated and necrotic. Not all discolored teeth need endodontic treatment ,sometimes dicolration may be caused by old amalgam restoration,root canal filling materials or medicaments or systemic medications.

y Many discoloration however are the result of disease

commonly associated with necrotic, gangrenous pulps, internal or external resorption and carious exposure. y CONTOURS: contours should be well examined because fractures ,wear facets,and restoration change the crown,s contour. y CONSISTENCY: consistency relates to the presence of caries ,internal and external resorbtion.

T ch iq f vis al a xa i ati

tactil

y One use eyes, finges ,explorer and periodontal probe. y Patients teeth and periodontium should be examined in good light under dry conditions. For example: A sinus tract might escape detection if it is covered by saliva OR inerproximal cavity may escape if it is filled with food. y Loss of translucency,slight color changes and cracks may not be apparent in poor light. Infact, Transluminator may aid in detecting enamel cracks or crown fractures. y VISUAL EXAMINATION: should include the soft tissue adjacent to the involved tooth,for detection of swelling.

y Periodontal probe should be routinely used to

determine the periodontal status of suspected tooth and adjacent tooth. Sinus tract opening into the gingival crevice or deep in infrabony pockets may go undetected because of failure to use periodaontal probe. y Periodontal pocket probing depths must be measured and recorded.A significant pocket in absence of periodontal disease may indicate root fracture.

GLIKMAN S CLASSIFICATIONy For furcation defects y Grade 1: incipient lesion when the pocket is suprabony

involving soft tissue and there is slight bone loss. y Grade 2: Bone is destroyed on one or more aspects of the furcation but probe can only penetrate partially into the furcation. y Grade 3: Intraradicular bone is comletely absent but the tissue covers the furcation. y Grade 4: through and through furcation defect.

Percussiony Percussion evaluate the status of the periodontium

surrounding a tooth. y Tooth is struck with a quick,moderate blow ,initially with low intensity and than with increasing intensity by using the handle of the instrument,to determine whether the tooth is tender. y A sensitive response to differing from that of adjacent teeth usually indicate presence of Acute apical perodontitis. y One must not percuss a sensitive tooth beyond the patients tolerance.

y Percussion is used in conjunction with other

periodontal tests, namely palpation, mobility,and depressibilty. These tests help to corroborate the presence of periodontitis.

Palpationtissue consistency and pulp response. y Although it is a simple test but its value lies inlocating the swelling over an involved tooth and determine : y (A) Whether the tissue is fluctuant and enlarged sufficiently for incision and drainage. y (B) Presence,intensity and location of pain y (C) Presence and location of Adenopathy y (D) Presence of bone Crepitus when the infection is confined to the pulp and has not progressed into the periodontium,palpation is not diagnostic. So, palpation is test for integrity of the attachment apparatus i.e periodontal ligament and bone not diagnostic when disease is confined with in the pulp cavity of tooth.y Simple test done with finger tip,using light pressure to examine

Mobility Depressibility Testy Mobility test is used to evaluate the integrity of the

attachment apparatus surrounding the tooth. y Test consist of moving a tooth laterally in its socket by using the fingers or preferably the handles of two instruments. y Objective is to determine whether the tooth is firmly or loosely attached to its alvelolus. y Amount of movement is indicative of the condition of the perodontium,greater the movement ,poorer the periodontium status.

Depressibility test consist of moving a tooth vertically in its socket. Test may be done with fingers or with instrument. When depressibility exists the chance for retaining the tooth ranges from poor to hopeless. TOOTH MOBILITY: Tooth mobility can be classified as : First degree: a noticiceable movement of tooth in its socket. Second degree: movement of tooth with in a range of 1mm. Third degree: movement greater than 1mm or when tooth can be depressed.

y Endodontic treatment should not be carried out on

teeth with third degree mobility unless mobility is reduced when pressure in the periodontium has relieved

Bite testy Bite test is useful in identifying a cracked tooth or fractured cusp. y Also help in diagnosing cases wherein the pulpal pathosis has extended in the periradicular region causing apical periodontitis. y Tooth slooth and Frac Finder is commercially available device for the bite test. y Clinician should note whether the discomfort or pain occurs during the act of biting or during the release of bite force. Pain on Biting Apical periodontitis Pain on release of biting force cracked tooth

RADIOGRAPHYy One of the most important tool in making a diagnosis. y It permits visual examination of oral structures that

would otherwise be unseen by the naked eyes. y Practice of dentistry would be impossible without radographs. y To use radiograph properly clinician must have the knowledge and skills to interpret them correctly. y clinician must know about underlying normal anatomical structures ,anomalous anatomy and the changes that occur due to aging , trauma ,disease and healing.

Electric pulp testingy More accurate method used to determine the pulp y y

y y

vitality. Electric pulp tester, when testing for pulp vitality uses nerve stimulation instead. Objective is to stimulate a pulpal response by subjecting the tooth to an increasing degree of electric current. Positive response indicates vitality and help in detemining the normality and abnormality of pulp. No response to electrical stimulus can be indication of pulp necrosis.

Tec ni ue of Pulp testing1.Describe the test to the patient in a way that will reduce anxiety and will eliminate a biased response. 2.Isolate the area of teeth to be tested with cotton rolls and saliva ejector and air dry all the teeth. 3.Check the electric pulp tester for function and determine that current passing through the electrode. 4.Apply the electolyte( toothpaste) on the tooth electrode and place against the dried enamel of crown s occlusobuccal and incisolabial surface. Avoid contacting any restorations in the tooth or adjacent gingival tissue with the electrolyte because it gives false response/ misleading response.

5. Retract the patient s cheek away from the tooth electode and the electical circuit is completed by either asking the patient to touch the metal handle or using a lip clip. 6. Turn the rheostat slowly to introduce minimal current into the tooth and increases the current slowly. Ask the patient to indicate when sensation occurs by using such words as Tingling and Warmth . Record the result according to the numeric scale on the pulp tester. 7. Repeat the foregoing for each tooth to be tested.

y Incisal third of the anterior and mid third of the

posterior teeth are the most ideal region for placing the tester because of highest nerve density.

T ermal testingy This test involves application of cold and heat to y

y y y

determine the sensitivity to thermal changes. Although both are tests of sensitivity , they are dissimilar and are conducted for different diagnostic reasons. A response to cold indicates a vital pulp,regardless of whether that pulp is normal or abnormal. A heat test is not a test of pulp vitality. An abnormal response to heat usually indicates the presence of a pulpal or periapical disorder requiring endodontic treatment.

Heat Testingy Heat test is performed using different techniques that deliever different degree of teperature. y Area to be tested is isolated and dried ,warm air is directed to the exposed surface of tooth. y If high temperature is needed hot water, hot burnisher , hot gutta percha and hot compound are used. y When using a solid substance such as guttta percha heat is applied to the occlusobuccal third of the exposed crown. If no response occurs, the host substance can be moved to the central portion of the crown or closer to the tooth cervical margin. y When a response occurs heat should be removed immediately .

y For the application of hot water a different technique is

used. y Tooth to be tested is isolated under a rubber dam. y Tooth is than immeresed in Coffee hot water delievered from a syringe. And than the patient reaction is noted.

Cold TestingCold test can be performed in several different ways. y A stream of cold air can be directed against the crown of previously dried tooth and also at the gingival margin. If no reaction occurs, tooth can be isolated under a rubber dam and sprayed with ethyl chloride which evaporates more rapidly. That it absorbs heat and there by cools the tooth. y More common method is apply a cotton pellet saturated with ethyl chloride spray to the tooth being tested. y Carbon dioxide spray (dry ice) can also be used for the application of cold to teeth. y Use of dry ice is described by : Ehrmann y Temperature of Dry Ice is -78 degree

Anaest etic testingy Restricted to patients who are in pain at the time of

test when the ususl tests have failed to identify the tooth. y Objective is to anaesthesize one tooth at a time untill pain disappears and is localized to a specific tooth. y Technique: using infiltration or intraligament injection,inject the most posterior tooth in the area suspected of being the cause of pain. if pain persist when the tooth has been fully anesthesized , anesthesize the next tooth mesial to it and continue to do so untill pain disappears.

y If pain can not be identified from maxillary or

mandibular origin an inferior alveolar block is given. Cessation of pain naturally indicate involvement of a mandibular tooth. y localization to a specific tooth is done by intraligament injection.

Test Cavityy Done for determination of pulp vitality. y Test cavity is made by drilling through the enamel-dentin juction of unanesthesized tooth.drilling should be done at slow speed and without a water coolant. y Sensitivity or pain felt by the patient is indication of pulp vitality; no endodontic treatment is indicated. y Sedative cement is then placed in the cavity and the search for the source of pain continues. y If no pain is felt, cavity preparation may be continued untill the pulp chamber is reached. y If the pulp is comletely necrotic ,endodontic treatment can be continued painlessly in many cases without anaesthesia.

Recent trends in vitality Assessmenty Most common methods to assess pulp vitality are

based on sensitivity assessment of the neutral tissues of pulp. These include thermal and electrical pulp tests. y True vitality statues can be ascertained only when we are able to assess the vascular or blood supply to the tooth. y Two recent technologies are: 1.Pulse oximetry 2.Laser doopler Flowmetry