DIAGNOSTIC PROCEDURES

Introduction Correct treatment begins with a correct diagnosis. Arriving at a right diagnosis requires knowledge, skill and art. The dictionary defines diagnosis as the art of identifying a disease from its signs and symptoms. Symptoms are units of information sought in clinical diagnosis. Symptoms are defined as phenomena normal and indicative of illness. Symptoms can be classified accordin ly! Sub!ective symptoms" are those e#perienced and reported to the clinician by the patient. $b!ective symptoms" are those ascertained by the clinician through various tests. %any diseases have similar symptoms. &ence the clinician must be astute in determining the correct diagnosis. Differential Dia nosis! This technique distinguishes one disease from several other similar disorders by identifying their differences. signs of a departure from the

'

 (iagnosis by e#clusion on the other hand, eliminates all possible diseases under consideration, until one remaining disease correctly e#plains the patients symptoms. T"us t"e criteria for on accurate clinical dia nosis includes! a good case history a thorough clinical e#amination relevant investigations diagnostic tests #edical $istory! )ven though there are virtually no systemic contraindicatios to endodontic therapy *e#cept uncontrolled diabetes or a very recent myocardial infarction+, a recent and succinct, comprehensive medical history is mandatory. ,t is only with such a history that the clinician can determine whether medical consultation or premedication is required before diagnostic e#amination or clinical treatment is undertaken. Some patients require antibiotic prophyla#is before clinical e#amination because, of systemic conditions like" &eart value replacement A history of rheumatic fever Advanced A,(S

,n case of patients who daily take anticoagulant medication may need to have the dose reduced or dosing suspended, especially in case of a periodontal e#amination.

.hen patients report being infected with communicable diseases such as A,(S, tuberculosis, &epatitis /, dentists and staff must use protective barriers.

The clinician must also know what drugs the patient is taking so that adverse drug reactions can be avoided.

0atients who present with mental or emotional disorders are not uncommon. ,n these cases too, medical consultation before the diagnostic e#amination would be in the best interests of the patient, (octor and Staff.

Dental $istory! After completing, the medical history, the clinician should develop the dental history. The purpose of a dental history is to create a record of the chief complaint, the signs and symptoms the patient reports, when the problem began and what the patient can discern that improves condition. The most effective way for the clinician to gather this important information is to ask the patient pertinent questions regarding the chief complaint and listen carefully and sensitively to the patient responses. /ecause dental pain frequently is the result of a diseased pulp, it is one of the most common complaints. worsens the

.hatever the reason, the patients chief complaint is the best starting point for a correct diagnosis.

Subjective Symptom" As mentioned before 0A,2 is a sub!ective symptom. 3udicious questioning of the pain can aid the

diagnostician in developing a tentative diagnosis quickly. $ne should ask the patient the following" the kind type of pain 4ocation of the pain (uration of the pain .hat causes the pain .hat alleviates it .hether it is referred to another site or not

Type / Kind of pain" 5enerally pulpal pain is described by the patient in one of the - ways. *a+ Sharp, piercing and lancinating 6 due to the e#cition of the A7delta8 nerve fibres *myelinated principal sensory fibres+ in the pulp. This pain may reflect on a reversible state of pulpitis. *b+ (ull, boring, growing and e#cruciating pain" due to e#citation and shower rate of transmission of the C8 nerve fibres *unmyelinated fibres+. This pain usually reflects on ,99):)9S,/4) STAT) $; 0<40,T,S.

Duration of pain! is present. At other times, it lasts for minutes to hours. ,n case of Acute reversible pulpitis. 0ain 6 short duration 6 disappears soon after removal of the stimulus. Sharp, lancinating and piercing <sually locali>ed ,s more responsive to cold than to heat. ,n case of irreversible pulpitis, 0ain 6 persists even after removal of the stimulus or irritant. (iffuse. 4onger duration. 9esponds abnormally to heat than to cold. At times pulpal pain lasts only as long as an irritant

%ocali&ation of pain! 0ain is locali>ed when the patient can point to spot a specific tooth or site with assurance and speed when asked to do so. <sually short, piercing, lancinating pain is easy to locali>e and responds promptly to cold.

 .hen the pain is diffuse, it relates to a dental pain that is dull, boring and gnawing. This pain can also be referred to other sites. Referred pain" At times pain is referred to other areas and even beyond the mouth. %ost commonly it is manifested in other teeth in the same or the opposing quadrant. &owever, referred pain is not necessarily limited to the other teeth. ,t may, for eg. be ipsilaterally referred to the preauricular area, or down the neck or up the temporal area. ,n these instances the source of e#traorally refereed pain almost invariably is a posterior tooth. 0atients may report that their dental pain is e#acerbated by lying down or bending over. This occurs because of the increase in blood pressure to the head, which increases the pressure on the confined pulp. Abnormal dental pain caused by heat usually requires endodontic treatment. 0ain that occurs on changing the position of the head, awakens the patient from sleep, or occurs during mastication of food in a cariously e#posed tooth usually indicates a need for treatment. Acute Re'ersible Pulpitis Irre'ersible Pulpitis

Pain: laminating, piercing. Sharp,

(ull, boring, growing e#cruciating pain longer duration.

0ersists Short even after removal of the stimulus duration 6 disappears soon after irritant. removal of the stimulus. 9esponds %ore abnormally to heat them to cold. responsive to cold. locali>ed. Ob(ecti'e Symptoms! $b!ective symptoms are determined by tests and observations performed by the clinician. These tests are as follows" Commonly used tests '. -. 1. =. ?. @. A. B. C. 'D. ''. :isual and tactile inspection 0ercussion 0alpation %obility and depressibility 9adiographs Thermal tests )lectric pulp test 0eriodontal e#amination Test cavity Anesthesia test $cclusal pressure test <sually (iffuse.

'-. '1. '=.

5utta7percha point tracing Transillumination Staining

Special #et"ods! '. Eero 6 radiography -. 0ulse 6 o#imetry 1. 4aser 6 (oppler flowmetry =. Computeri>ed Tomography ?. (igital subtraction radiography @. %.9.,. A. 9.:.5. B. Computeri>ed e#pert system 1. Visual and Tectile Inspection" This is one of the most simplest clinical tests. Too often, it is done only causally during e#amination, and as a result, much essential information is lost inadvertently. A thorough visual, tactile e#amination relies on checking the 1Cs8 7 Colour, Contour, Consistency. In case of soft tissues" such as gingiva 6 any deviation from the healthy, pink colour is readily recogni>ed when inflammation is present. ontour" a change in contour occurs when there is swelling.

onsistency" a change in consistency from normal, healthy firm tissue to that of a soft, fluctuant or spongy tissue indicates a pathologic condition. In case of !ard tissues" even the hard tissues i.e. the teeth should be visually e#amined using the 1 Cs8. olour" a normal appearing crown has a lifelike translucency and sparkle that is missing in pulpless teeth. Teeth that are discoloured, opaque and less lifelike in appearance should be carefully evaluated. /ecause the pulp may already be inflammed, degenerated or necrotic. 2ot all the discoloured teeth will require endodontic treatment. Staining maybe caused by old amalgam restorations, root canal filling materials and medicaments, or systemic medication, such as tetracycline staining. %any discolourations, however, are the result of disease commonly associated with nectrotic and gangrenous pulps, internal or e#ternal resorption, carious e#posure. ontour" crown contours should be e#amined. Causes for changes in the crown contour could be: ;ractures .ear facets 9estorations

The clinician should be prepared to evaluate the possible effects of such changes on the pulp.

onsistency" of the hard tissue relates to the presence of caries and internal or e#ternal resorption. Techni#ue" the technique of visual and tactile e#amination is simple. ,t can be done with oneFs fingers, an e#plorer and the periodontal probe. The patients teeth and periodontium should be e#amined in good light under dry conditions. For Example" a sinus tract *fistula+ might escape detection if it is covered by saliva or an interpro#imal cavity may escape notice if it is filled with food. 4oss of translucency, slight colour changes and cracks may not be apparent in poor light *in such cases, a trasilluminator may aid in detecting enamel Cracks Crown Gs+ :isual e#amination should also include the soft tissues ad!acent to the involved tooth, for detection of swelling. The crown of the tooth should be carefully evaluated, to determine whether it can be restored properly after completion of endodontic treatment. ;inally, a rapid survey of the entire mouth should be made, to ascertain whether the tooth requiring treatment is a strategic tooth. )* Percussion!

'D

 ,n percussion, the crown of a tooth is tapped with the tip of a finger or with an instrument. A painful response to percussion denotes inflammation of the periodontal membrane. Although percussion is a simple method of testing, it may be misleading if used alone. ,n performing the test, several teeth are percussed in a random order, to eliminate bias on the part of the patient. ,nitially a suspect tooth should be tapped very gently, since the periodontal membrane maybe e#tremely tender. ,f there is no response a sharp tap is given. $ne should change the direction of the blow from the vertical occlusal to the buccal or lingual surfaces of the crown and strike separate cusps in a different order. ,t must be born in mind that tenderness to percussion does not necessarily denote pulpal disease. A tooth with a healthy pulp may develop on acute apical periodontitis from a blow or premature occlusal contact. or an acute periodontitis maybe the sequel to food packing between two teeth. The absence of a response to percussion is quite possible when there is chronic periapical inflammation.

''

,f a metallic instrument is used, the sound produced by percussing a tooth with periapical disease is sometimes obviously duller than that given by a tooth with an intact periape#. $. %alpation" in this simple test, light pressure is applied with the fingertip, to e#amine tissue consistency and pain response. Although simple, it is an important test ,ts value lies in locating the swelling over an involved tooth and determining the following" i. whether the tissue is fluctuant and enlarged sufficiently for incision and drainage. ii. iii. iv. the presence, intensity and location of pain the presence and location of adenopathy the presence of bone crepitus.

.hen palpation is used to determine adenopathy, it is advisable to e#ercise caution when palpating the lymph nodes, in the presence of an acute infection, to avoid the possible spread of infection through the lymphatic vessels. Dia nostically! .hen posterior teeth are infected, the subma#illary lymph modes become involved. .hen anterior teeth are involved, the submental lymph nodes become involved.

'-

Tenderness over the root ape# of a tooth indicates inflammation of the periodontal membrane. /ut this can also result from other causes other than pulpal diseases. )#cluding absess formation associated with periodontal disease, swelling of the mucosa over the root ape# of a tooth denotes partial or complete necrosis of the pulp. .hen the infection is confined to the pulp and has not progressed into the periodontium, palpation is not diagnostic. 0alpation, percussion, mobility and depressibility test the integrity of the attachment apparatus i.e. the periodontal ligament and bone, and are not diagnostic when the disease is confined within the pulpcavity of a tooth. ,n short, palpation, mobility and depressibility are tests of the periodontium rather than of the pulp. +* #obility , Depressibility testin " The mobility test is used evaluate the integrity of the attachment apparatus surrounding the tooth. The test consists of moving a tooth laterally in its sockets by using the fingers or preferably, the handles of two instruments. The ob!ective of this is to determine whether the tooth is firmly loosely attached to its alveolus.

'1

 The amount of movement is indicative of the condition of the periodontium. The greater the movement, the poorer the periodontal status. Similarly, the test depressibility consists of moving a tooth vertically in its socket. This test may be done with the fingers or with an instrument. .hen depressibility e#ists, the chance of retaining the tooth ranges from poor to hopeless. Classification of mobility" *According to 5rossman+ i+ ii+ ;irst degree mobility" is barely discernible movement. Second degree mobility" is a hori>ontal movement of ' mm or less.

iii+ Third degree" is a hori>ontal movement of greater than 'mm, often accompanied by a vertical component of mobility. The pressure e#erted by the purulent e#udates of an acute apical abcess may cause some mobility of a tooth. ,n this situation the tooth may quickly stabili>e after drainage is established and occlusion is adusted. &dditional causes for tooth mobility" '. Advanced periodontal disease. -. &ori>ontal root fracture in the middle and coronal third. 1. Chronic bru#ism clenching. Note on #obilometers!

'=

These are electronic devices tooth mobility.

gadgets which aid in determining

The apparatus essentially consists of two electrodes or prongs which hold the facial and lingual surface of the teeth. The degree of mobility tested is then reflected as a numerical reading either on the instrument itself or on an attached computer screen. Radio rap"s! The radiograph is one of the most important clinical tools in making a diagnosis. /ut some clinicians rely e#clusively on radiographs to arrive at a diagnosis which can lead to ma!or errors in diagnosis and treatment. /ecause the radiograph is a two dimensional image of a 17dimensional ob!ect, misinterpretation is a constant risk. To use radiographs properly, the clinician must have the knowledge and skill necessary to interpret them correctly. A thorough understanding is required of the underlying normal or anomalous anatomy and the changes that can occur due to aging trauma, disease and healing. ,t is important that radiographs be of e#cellent quality. To produce an e#cellent radiograph one must master the necessary skills" '. 0roper placement of the film in the patientFs mouth.

'?

-. Correct angulation of the cone in relation to the film and oral structures *to prevent distortion of the anatomic images+. 1. Correct e#posure time 6 so the images are recorded with identifiable contrasts. =. 0roper developing technique. Radio rap"s can contain information on! '. 0resence of caries that may involve or may threaten to involve the pulp. -. The number course, shape, length and width of the root canals. 1. the presence of calcified material in the pulp chamber or root canal. =. the resorption of dentin originating within the root canal internal resorption or from the root surface *e#ternal resorption+. ?. Calcification or obliteration of the pulp cavity. @. Thickening of the periodontal ligament. A. 9esorption of cementum. B. 2ature and )#tent of periapical and alveolar bone destruction. C. 9oot ;racture. .hen posterior teeth are being investigated, a bite wing film provides an e#cellent supplement for finding the e#tent of carious destuction, the depths of restoration, the presence of pulp caps or pulpotomies and dens evaginatus or invaginatus.

'@

Root fractures" These could be difficult to detect on a radio graph, especially vertical root fractures which can be identified only in advanced cases of root resorption. &ori>ontal fractures maybe confused radiographically with linear patterns of bone trabecule. The two can be differentiated by noting that the lines of bone trabeculae e#tend beyond the border of the root while root fractures often cause thickening of the periodontal ligament.

'A

Difference bet-een internal and e.ternal resorption! (ifferentiation between internal and e#ternal resorption maybe made radiographically" '. The lesion of internal resorption usually has sharp smooth margins that can be clearly defined. &owever, it need not be symmetrical. -. The pulp disappears8 into the lesion not e#tending through *i.e. the shadow of the pulp+ the lesion in its regular shape. Radio rap"ic misinterpretation! ,n some instances two or more e#posures are necessary to check out detail from more than one hori>ontal angle. This is especially in the case of the mental foramen 6 this foramen maybe directly superimposed over the ape# of the mandibular premolars for e#ample. The nasopalatine foramen also maybe superimposed on the ape# of the ma#illary central incisors. These foramina are actually some distance from the apices of these teeth. To find out whether it is a foramen or truly a periapical lesion one must change the hori>ontal angle of the cone of the #7ray machine to the mesial distal during separate e#posures. ,f the radiolucent arc is actually a lesion associated with the periape# than its shadow will remain attached8 to the root end despite of a mesial or distal shift in separate films.

'B

%esions -it"in t"e toot" obser'able by radio rap"s! a. 0ulp death in a developing tooth is readily apparent because the root ceases to develop. b. 0ulp stones, inflammation. c. ,nternal resorption seen following traumatic in!ury. %esions outside t"e toot" obser'able on radio rap"s! Some of the most common occurrences seen radiographically on the out side of the root of the tooth are 6 a. .idening of periodontal space occurring due to Acute apical periodontitis. Acute apical abscess $cclusal trauma.

b. Changes associated with chronic periapical abscess. c. )#ternal root resorption. ,n case of e#ternal root resorption" lesion has ragged margins and shadow of the pulp passes through8 the lesion unaltered. RADIOGRAP$ ANGU%AR , PERIRADICU%AR %ESIONS #ost often t"e follo-in features are seen! .idened periodontal ligament space ,nflammatory apical root resorption

'C

 infection.

%ost often associated with pulp necrosis and

Ot"er conditions -"ere one can notice a -indened PD% space are! Acute apical periodontitis A beginning acute apical abscess Acute pulpitis *occasionally+

Radio rap"ic c"an es as se/uelae to pulp necrosis T"e commonly obser'ed c"an es are! a+ Chronic apical periodontitis 6 a well circumscribed osseous lesion 9adiolucent area varying in si>e from a few mms to a cm or larger in si>e /order bony perimeter maybe radiopaque. (o not always occurs at the periape# occasionally seen on the lateral surface of the root in association with an accessory canal. b+ Chronic apical abscess" lesion. c+ Apical cyst" may develop from a chronic abscess. ,n this case lesion appears 6 more circumscribed, more like a granuloma8 in appearance. 4arger, more diffuse and irregular radiolucent

-D

 ,t also moves roots of teeth laterally. NAT0IN has postulated that the larger the lesion the more apt it is to be a cyst. A number of pathologic changes in and near the alveolar process maybe mistaken for periradicular lesions of pulpal origin. They are" I. Lesions of non endodontic origin: '. 5lobuloma#illary cyst 6 inverted pear shaped. -. %idline palatal cyst 6 occurs in the midline. 1. Cyst of the nasopalatine canal or foramen 6 occurs mainly in the palatine process. II. Periodontal lesions" maybe mistaken for periradicular ones. The periodontal probe and pulp tester are invaluable in determining the origin of the lesion. Another method is to place a silver or gutta percha point in the periodontal pocket and take a radiograph. III.Cementoblastoma" common errors in diagnosis center around the lesions of cementoblastoma particularly during stage , when radiolucency is so apparent. *$nce it begins to calcify into a selerotic lesion, little doubt should e#ist about the nature of the lesion+. 1* T"emal testin !

-'

$ne of the most common symptoms associated with a symptomatic inflammed pulp is pain induced by hot or cold stimulation. &ot and cold tests are valuable diagnostic aids.

According to 5rossman, 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 and 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. Another diagnostic difference pointed out by 5rossman is that when a reaction to cold occurs the patient can quickly point out to the painful tooth. .hereas in a heat test, the response could be locali>ed or diffused or even referred to a different site. The results of the thermal test should be correlated with the results of other tests to ensure validity. Tec"ni/ue of performin t"ermal tests! /efore testing, the patient should be told what tests are going to be performed and why. Additionally, the patient should be given some idea of what to e#pect.

--

 The tests should be first performed on teeth which are to be used as controls i.e. corresponding *if found+ on the opposite side of the same arch. Contralateral teeth can also be used as controls. /y doing so, the patient gets an idea of how the tests will feel. The dentist should also inform the patient how to respond when a sensation is e#perienced. For Eg" The patient should be instructed to raise a hand as soon as any sensation is felt. The heat or cold test (e en EPT! tests are performed b" placing the stimuli on: &nterior teeth" labial *enamel+ surface of the incisal third of the crown. %osterior teeth" $ccluso /uccal surface. &owever, placing the stimulus on e#posed dentin should be avoided 6 because an accelerated or e#agerrated response is likely. Also the stimulus should not be applied against restorations unless unavailable. 2on7metallic restorations" 0oor conductors tests gives a delayed response or no response 'etallic(restorations" 5ood conductors This can result in response at low levels of stimulation. They may also cause misleading results by conducting the stimulus to an ad!oining metallic restoration in another tooth.

-1

 This effect can be reduced by placing a celluloid strip between the teeth. The teeth in the quadrant must first be isolated and then dried with -#inch gua>e and a saliva e!ector placed. Cohen states that teeth should not be dried with a blast of air because 9oom temperature air might cause shock. Saliva might be sprayed on the clinician or the assistant. !eat Test" The heat test can be performed using different technique that deliver different degrees of temperature. According to Cohen the preferred temperature is @?.?HC *'?DH;+. /ut according to A&9 9owe et al in his article on Assessment of pulpal vitality *,nt )nd 3ournal 'CCD :7-1+ temperatures upto '?DHC are necessary for conducting thermal tests on teeth which are first smeared with :aseline to avoid g.p. sticking to tooth. #eat testing can be made with &ot air blast &ot water &ot burnisher any instrument which can deliver controlled temperature to the tooth &ot 5utta7percha

.here a gold crown is present, heat maybe applied by polishing the crown with an Abrasive disc.

-=

.hen testing with gutta7percha, it is heated over an alcohol flame until it becomes shiny and sags, but before it begins to smoke. Care should be taken not to place an overheated gutta percha stick or prolonged application of the stick as it may cause a burn lesion in an otherwise normal pulp. A different technique is required for the application of hot water. $ethod" ,solate with rubber dam Tooth is immersed in Coffee hot8 water delivered from a syringe. *According to Cohen this is the best method for thermal testing teeth with porcelain or full metal coverage+. )isadvanta*es" The response noted is limited to only the tooth which is tested. old Test" ;or the cold testing, the teeth must remain isolated and dry. The most common techniques for cold testing utili>e, '. A stream of cold air from a 1 way syringe directed against the crown of a previously dried tooth. -. )thyl chloride spray 6 it is sprayed liberally on a *evaporates rapidly by absorbing heat and cooling the tooth surface+ cotton pellet and held against the middle 1rd of the facial surface. The ethyle chloride technique is effective even on teeth covered with cast metal crowns.

-?

1. Sticks of ice =. Carbon dio#ide snow in the form of dry ice pencil. This produces lower intrapulpal temperatures than other methods *Aisberger and 0eters 'CB'+. ,s far more effective *)hrmann, 'CA1+. 9eliable even in immature teeth. Responses to t"ermal tests! The patients responses to heat and cold testing are identical because the neural fibres in the pulp transmit only the sensation of pain *&ydrodynamic theory 6 /rannstorm+. There are four possible reactions the patient may have" '. 2o response 6 pulp maybe non vital $r vital, but giving a false negative response because of )#cessive calcification ,mmature ape# 9ecent trauma 0atient premedication -. A mild to moderate transient thermal pain response. This is usually considered normal. 1. A strong, painful response that subsides quickly after removal of the stimulus 6 this is characteristic of 9eversible pulpitis.

-@

=. A strong, painful, response that lingers after the thermal stimulus is removed 6 this indicates a symptomatic irreversible pulpitis. %odification of technique for thermal tests" A modified technique for the heat and cold thermal tests is provided by the analytical technique pulp tester which has a hot probe tip and a cold probe tip. The heating of the hot probe tip and cooling of the cold probe tip are controlled separately in the membrane switch on the control panel. 2* Electric Pulp Tests! The electric pulp tester is designed to stimulate a response by electrical e#citation of the neural elements within the pulp. &istorically, the )0 tester has been used in dentistry since as early as 'B@A and has evolved over the years into the present electronic digital pulp tester. ,t is a valuable tool for diagnosis because not only does it help the clinician in determining pulp vitality but with thermal and periodontal tests it can also aid in differentiating among radiographic signs of pulpal, periodontal or non odontogenic cause. pulp is vital or non vital. ,t does not provide any information about the health or integrity of the pulp. The )0 test merely suggests whether the

-A

 vitality. Techni#ue"

,t does not provide any information about the vascular supply to the tooth, which is the real determinant of

'. (escribe the test to the patient in a way that will reduce an#iety and will eliminate a biased response. To eliminate a biased decision )0T should first be performed on a normal healthy tooth *control+, ad!acent or contra lateral. This aids in determining the patients threshold level. -. ,solate the area of teeth to be tested with cotton rolls and a saliva e!ector and air dry all the teeth. 1. Check the electric pulp tester for function, and determine that current is passing through the electrode. =. Apply an electrolyte *tooth paste+ on the tooth electrode and place it against the dried enamel of the crownsF occlusobuccal or inciso labial surface. All restorations must be avoided because they may cause a false reading. ?. 9etract the patients cheek away from the tooth electrode with the free hand. This hand contact with the patients cheek completes the electrical circuit. @. Turn the 9heostat slowly to introduce minimal current into the tooth and increase the current slowly.

-B

0atients should be instructed to raise a hand as soon as they begin to feel slight tingling or sensation of heat.

9ecord the result according to the numeric scale on the pulp tester.

)ach tooth should be tested - or 1 times and the reading averaged. Reason" The patientFs response may vary slightly *which is common+ or significantly *which suggests a false positive or negative the response+. 3actors 4 affectin le'el of Response! '. )namel thickness" Thicker the enamel, the more delayed the response. *Thin anterior teeth 6 respond faster, /road posterior teeth 6 slower response 6 because of greater thickness of enamel and dentin+. -. 0robe placement on the tooth. *0osterior teeth" occlusal third, anterior teeth" ,ncisal third 6 to avoid false stimulation of gingival tissue+. 1. (entin calcification =. ,nterfering restorative materials. ?. The cross sectional area of the probe tip @. patient level of an#iety. Ad'anta es of E*P*T! '. ,ntensity of stimulus is comfortable to the patients.

-C

-. The digital display of many ).0. Testors provides instant, easy and reliable information. 1. ,n some ).0. testers, a red indicator light flashes on and off when ma#imum stimulus is reached. =. 5ives a quantitative reading which can be compared with the normal reading of control tooth. Disad'anta es of EPT! '. ,t cannot be used on patients having cardiac pacemaker because of potential interference with the pacemaker. Studies by woolley and associated have shown that currents of the magnitude of ? to -D milliamps are sufficient to modify normal pacemaker function. -. <sually cannot be used when gloves are worn. ,n order to stimulate the pulp nerve fibers, the electric current must complete a circuit. &and contact with the patients cheek completes the circuit. .ith gloved hands that connection is interrupted. 1. Some ).0. Testers are very e#pensive. =. )0T is not useful on recently erupted teeth with immature ape#. Studies have shown that newly erupted teeth have more unmyelinated a#ons than do mature teeth the speculation being that some of these larger fibres may ultimately become myelinated. Since it is principally the pulpal A fibers that respond to electric pulp testing, variability in the number of IAF

1D

fibres entering the tooth offers a possible e#planation to why electric pulp tests tend to be unrealiable in young teeth. ?. 9ecently traumati>ed teeth cannot be tested. @. The probe tip of some )0T is removable and it falls out easily. A. 2o indication is given regarding the state of vascular supply which would give a more reliable measure of the vitality of the pulp. B. 9eadings from posterior teeth with partial vital pulps maybe misleading. *because in multirooted teeth one canal may have vital pulp tissue and other canals necrotic tissue+. +alse Readin*" As stated, the results from the )0T could be misleading and these could be grouped as" A+ ;alse positive response" means the pulp is necrotic but the patient nevertheless signals that he feels sensation. /+ ;alse negative response" means the pulp is vital but the patient appears unresponsive to electric pulp tests. #ain reasons for a false positi'e response! '. Conductor )lectrode contact with a larger metal restoration *bridge,

class ,, restoration+ or the gingiva allowing the current to reach the attachment apparatus. -. 0atient an#iety. 1. 4iquifaction necrosis may conduct current to the attachment apparatus and the patient may slowly raise his hand near the highest range.

1'

=. ;ailure to isolate and dry the teeth properly. #ain reasons for a false , ne ati'e response! '. 0atient heavily premedicated with analgesics, narcotics, alcohol or tranquili>ers. -. ,nadequate contact with the enamel. 1. 9ecently traumati>ed tooth. =. )#cessive calcification in the canal. ?. (ead batteries or forgetting to turn on the pulp tester. @. 9ecently erupted tooth with an immature ape#. A. 0artial necrosis *Although the pulp is still partially vital, electric pulp testing may indicate that it is totally necrotic+. Types of pulp testers! Two types of electric pulp tester are available ,. '+ Current is varied -+ :oltage is varied ,,. '. %onopolar -. /ipolar

The former in which current is varied is considered preferable, since a given voltage may lead to different amounts of current due to variation in the electrical resistance of the tissues, especially enamel. The common commercially available testers are"

1-

'. Analytic technology pulp tester" &ere the wave form has an output in the form of bursts of ten high frequency pulses followed by a space. This is done to minimi>e patient discomfort. The )0T is turned on automatically when the probe touches the tooth and is turned off when the tooth contact is broken *after a delay of '? secs+. There is a digital display and the only control on the )0T is the rate of increase of the stimulus. To complete circuit patient may touch metal handle. -. (igilog pulp tester 1. 5reen wood pulp tester =. 0elton crane pulp tester ?. 0arkell pulp tester *battery operated+ Periodontal E.amination! 2o dental e#amination is complete without careful evaluation of the teethFs periodontal support. The periodontal probe should be an integral part of all endodontic tray set ups. <sing a periodontal probe, the clinician e#amines the gingival sulcus and records the depths of all pockets.

11

%ultirooted teeth are carefully probed to determine whether there is any furcation involvement.

A lateral canal e#posed to the oral cavity by periodontal disease may become the portal of entry for to#ins that cause pulpal degeneration.

To distinguish lesion of periodontal origin from those of pulpal origin, thermal and electric pulp tests, along with periodontal e#amination are essential.

5* Test Ca'ity! This method is performed when other diagnostic methods have failed. ,t involves the slow removal of enamel and dentin to determine pulp vitality. .ithout anesthesia and using a small round bur, the dentist removes the dentin with a revolving high speed bur aimed directly at the pulp. ,f the pulp is vital, the patient will e#perience a quick sharp, pain at or shortly beyond the dentin enamel !unction. A sedative cement can then be placed in the prepared cavity and the search for the cause of pain may be continued. $n the contrary, if no pain sensitivity is recorded, the cavity

preparation maybe continued until the pulp chamber is reached and if the pulp is noticed to be necrotic, routine endodontic treatment could be performed.

1=

67* Anest"esia test! ,n the uncommon circumstance of diffuse strong pain of vague origin, when all other tests have failed, the Anesthesia test is performed. $b!ective" To anestheti>e a single tooth at a time until the pain disappears and is locali>ed to a specefic tooth. Techni#ue" <sing either infiltration or the intraligament in!ection, in!ect the most posterior tooth in the area suspected of being the cause of pain. ,f pain persists, when the tooth has been fully anestheti>ed, anestheti>e, the ne#t tooth mesial to it and continue to do so until the pain disappears. ,f the source of pain cannot be determined whether in ma#illary or mandibular teeth, an inferior alveolar *mandibular block+ infection should be given. Cessation of pain naturally indicates involvement of a mandibular tooth, and locali>ation of the specefic tooth is done by the intraligament in!ection, when the anesthetic has spent itself. This test is obviously a last resort and has an advantage over the Test cavity8, during which iatrogenic damage is possible. 66*,cclusal pressure or -itin* test" A frequent patient complaint is pain on biting or chewing. auses for such symptoms" 7 Apical periodontitis, 7 Apical abscess

1?

7 ,ncomplete tooth fractures A clinical test that simulates the chief complaint is the occlusal pressure test or biting test. 'ethod" Several methods e#ist like biting on" $rangewood stick /urlew rubber disc .et cotton roll The oragnewood stick and /urlew rubber disc allow pinpoint testing of individual cusp area. The wet cotton roll has the advantage of adapting to the occlusal surface allowing for pressure over the entire occlusal table. An interesting clinical observation in patients with tooth infarctions *Cracked Tooth Syndrome8+ is pain often e#perienced when biting force is released rather than during the downward chewing motion. 68* Gutta4Perc"a Point Tracin ! Techni#ue" 0lace a gutta percha point through the sinus take a radiograph. This can locali>e endodontic lesion to the specific tooth. ,n addition, this test aids in the differential diagnosis between a periodontal and an endodontic lesion. 6)* Transillumination 9 #a nification! fistulous tract and

1@

 ;iberoptic

lighting

and

chairside

magnification

have

become

indispensable in the search for cracks, fractures and unfound canals and obstructions in root canal therapy. The fact that magnification *e.g. microscopes+ and trasillumination might allow the dentist the only means of diagnosing an offending cracked tooth is becoming an increasing reality. 6:* Stainin*" The purpose of a staining test is isolation of a cracked tooth. Techni#ue" there are 1 methods to stain a tooth. '. 9emove the filling from the suspected tooth and place -J ,odine in the cavity preparation. The iodine stains the fracture line fracture lines can be identified with food colouring placed on the dried occlusal surface. The dye solution stains the fracture line. The occlusal surface is cleaned with a cotton pellet lightly moistened with ADJ isopropyl alcohol. The alcohol washes away the food coloring on the surface, but the colouring within the fracture line remains and becomes apparent -. %i# a dye in >inc o#ide eugenol cement and place it in the cavity preparation after filling has been removed. The dye will seep out and line the fracture. 1. &ave patient chew a disclosing tablet after taking out the filling of the fractured tooth. The fracture line will be stained. SPECIA% #ET$ODS

1A

6*

;eroradio rap"y! Eeroradiography is an imaging technique that has been proposed as an

alternative to conventional #7ray film radiography. The term #ero7radiography is derived from the greek word #eros8 which means dry8. Techni#ue" The #7ray image is recorded on a photo7conductive selenium coated plate rather than #7ray film. /efore use, the selenium plate is given a uniform electrostatic charge, placed in a light proof plastic cassette, positioned in the mouth, e#posed to #7 ray. The processed image is transferred onto clear adhesive tape and fi#ed on to an opaque plastic base. The resulting image maybe viewed either as a photograph with reflected light or as a radiograph with transmitted light from a view bo#. Ad'anta es! '. The radiation e#posure is ' 1rd that of the conventional #7ray film. -. /etter edge enhancement and image quality. 1. Eeroradiographs have inherently wide latitude. i.e. it is possible to image ob!ects having a broad range of densities in a single e#posure. .ide latitude also means the acceptable images can be obtained over a relatively broad range e#posure conditions.

1B

%d antage is 6 it can dramatically reduce the number of e#posures that have to be repeated because of technical inadequacies. The height of alveolar crest is often well demonstrated, aiding in diagnosis of periodontal disease. Caries maybe seen readily. =. ,t produces permanent dry image for viewing in about -D seconds. ?. The plates maybe reconditioned, recharged and used repeatedly.

1C

8* Pulse O.imetry! Tests relying on the passage of light through a tooth have been considered as a possible means of detecting pulp vitality with greater ob!ectivity. The pulse o#imeter is a non7invasive $ - saturation monitor that provides continuous pulse rate readings. The liquid crystal display *4C(+ gives o#ygen saturation, pulse rate and plethysmpographic wave form readings. oncept" 0ulse o#imetry uses red and infrared wave length in order to transilluminate a tissue bed and detects absorbance peaks due to pulsative circulation. This information is used to calculate the pulse rate and o#ygen saturation. The tooth to be tested is sandwiched between a photoelectric detector and red and infrared light emitting diodes. This method is clearly superior to other vitality tests since it does not rely upon sensory nerve response. *$ther routine methods rely on stimulation of a7delta nerve fibres for assessment of pulp vitality+.

=D

)* %aser Doppler 3lo-metry! (ue to the biased, false 6ve and positive responses elicited through the )0T the need for a better and more reliable method for determining pulp vitality arose. A method which determined and registered the blood flow rather than the neural response was preferred. 4(; was thus introduced first in 'CA- to determine blood flow in 9etina of 9abbits 6 9,:A, 9oss and /enedek as a non7invasine method to measure blood flow. The cru# of the 4(; is based on the detection of movement of blood cells in the pulpal blood vessels, with thus gives a true picture regarding pulp vitality. Techni#ue" essentially consists of a laser light i.e., helium neon laser at @1-.Bnm. ,t is focused on the tissue under study with a fiber optic probe. As the light hits the various components of the tissues, it is partially absorbed and partially back scattered. The bac& scattered light has ' components: i+ 4ight back7scattered from the static tissues which has the same frequency as the light going on. ii+ The other component is the (oppler shifted light with a different frequency.

='

The back scattered light is processed and an ouput signal is produced i.e. both the unshifted an shifted light is transmitted to a detector by optical fibres where it is charged into an electric current and processed. The detected output signal can be fed onto an analog printer, or be rand from a digital board. Ad'anta es of %D3! '. 2on7invasive. -. Simple to apply. 1. 0rovides a continuous record. =. <seful to demonstrate establishment of vitality of untreated teeth. Disad'anta es! '. ,mpossible to calibrate the readings in absolute units. -. $utput may not be linearly related to blood flow. :* Computeri&ed Tomo rap"y! Computed tomography was introduced in the mid 'CADFs. Computed tomographic systems are also referred to as computed a#ial tomography scanners *CAT+. CT scanners produce digital data measuring the e#tent of #7ray transmission through an ob!ect. This numerical information maybe transformed into a density scale and used to generate or reconstruct a visual image. Tachibana, has reported about the use of #7ray CT in endodontics.

=-

 ,t is possible to determine the bucco7lingual and mesio7distal widths of teeth and the presence or absence of root canal filling materials and metal posts. Also observable are the carious lesions, e#tension of the ma#illary sinus and its pro#imity to the root apices. Ad'anta es! '. $bservation of structures which are difficult to visuali>e with conventional #7rays. -. 0rovides images for 17dimensional image of roots, root canals and teeth. Disad'anta es! '. )#pensive -. Skin dose is large 1. Time consuming. +* Di ital subtraction radio rap"y! The progress of caries from an incipient lesion, the ()3 is often difficult to detect. 4ikewise, the assessment of healing or e#pansion of the periapical lesion after root canal therapy is a challenge therefore the subtle changes in the density of the lesions maynot be detectable with the naked eye. Subtraction radiography offers a remedy for these problems.

=1

 ,t is an image enhancement method. &ere, the area under focus is clearly displayed against a neutral gray black background or it is superimposed on the radiograph itself *i.e. the required areas are enlarged against the entire background+. This (S9 maybe used to assess the successfulness of 9CT and also periapical lesions. <* Radio'isuo rap"y! 9:5 digiti>es ioni>ing radiation and provides an instantaneous image on a video monitor, thereby reducing radiation e#posure by BDJ. The RV. has / components" '. 9adio component" consists of an hypersensitive intra oral sensor and a conventional #7ray unit. -. :isio8 portion" consists of a video monitor and a display processing unit. 1. 5raphy8 portion" is a high resolution video printer that provides an instant hard copy of the screen image using the same video signal. Ad'anta es! '. )limination of E7ray film -. Significant reduction in e#posure time. 1. ,nstantaneous image display The 9:5 system appears promising for the future of endodontics.

==

/ut, the resolution of 9:5 is slightly lower than that produced with conventional film, which can however be improved through enhancement procedures. 1* Computeri&ed e.pert system! 9eported by 3ohn ;irrola, the C)S :i>, Comende# was used for the diagnosis of selected pulpal pathosis i.e. 2ormal pulp 9eversible pulpitis. ,rreversible pulpitis *due to hyperocclusion+. 2ecrotic pulp ,nfection due to endodontic failure. Appropriate diagnostic case facts are obtained and this data is entered into the computer. The computer checks and gives out the diagnosis. 7 diagnosis. Conclusion! To conclude, , would like to say that one cannot depend solely on these tests to arrive at a diagnosis. 7 right diagnosis. As mentioned before, the clinicians knowledge, skill and art combined with these diagnostic tests will help one to make the .ith rapid advances being made in the field of computers one can e#pect more efficient programmes for endodontic

=?

=@