Diagnostic procedures in endodontics

Asallam Alekkum
Dr. Gaurav Garg, Lecturer
College of Dentistry, Al Zulfi

Diagnosis is a process of determining the nature of
a disease.
very important for proper treatment.
Differential diagnosis is the process of
differentiating between similar diseases.
For correct differential diagnosis:
 Proper knowledge of the disease
 Skill and Art on how to apply proper diagnostic
methods

A good clinician has to be a good
diagnostician.
Qualities of a good diagnostician-
Knowledge
Interest
Intuition
Curiosity
Patience

As stated by Grossman, are phenomenon or
signs of a departure from the normal, and are
indicative of an illness.
Types:
1. Subjective Symptoms are those which are
experienced and reported to the clinician by the
patient.
2. Objective Symptoms are those, which are
obtained by the clinician through various tests.

Lingering tooth sensitivity to cold liquids.
Lingering tooth sensitivity to hot liquids.
Tooth sensitivity to sweets.
Tooth pain to biting pressure.
Tooth pain that is referred from a tooth to another
area, such as the neck, temple, or the ear.
Spontaneous toothache, such as that experienced
while reading a magazine, watching television, etc.
Constant or intermittent tooth pain.
Severe tooth pain.
Throbbing tooth pain.
Tooth pain that may occur in response to postural
changes, such as when going from a standing to a
reclining position.

Good case history:
 Chief complaint
 Past medical history
 Past dental history
 Also includes vital signs, history of presenting illness.
• It is essential to gather collective information
regarding signs, symptoms, and history for a
successful outcome of any treatment procedure.
Thorough clinical examination
Relevant investigations / diagnostic tests

Hardly exists any contraindication except:
 Uncontrolled Diabetes
 A very recent Myocardial infarction
Aid the dental clinician in deciding whether a
prior medical consultation or pre-medication
(chemo-prophylaxis) would be required

Cardiovascular:
 High & moderate risk of Endocarditis
 Pathologic heart Murmers
 Hypertension
 Unstable angina
 Recent myocardial infarction
 Arrythmias
 Poorly managed congestive heart failure.
Pulmonary:
 COPD
 Asthma
 Tuberculosis

GI & Renal:
 End stage renal disease , Hemodialysis
 Viral hepatitis( B,C,D,E)
 Alcoholic liver disease
 Peptic ulcer disease
Endocrine & Hematologic:
 STDs, HIV & AIDS
 Diabetes mellitus
 Adrenal insufficiency
 Hyperthyroidism
 Pregnancy
 Bleeding disorders
 Cancer & leukemia
 Osteoarthritis, rheumatoid arthritis, SLE.
NeurologicDisorders

Side effects of medications:
 Stomatitis, xerostomia, petechiae, ecchymosis, lichenoid
lesions & mucosal & gingival bleeding.
Lymphoma or Tuberculous involvement of cervical &
submandibular lymph nodes
Immunocompromised & patients with uncontrolled Diabetes
Patients with iron deficiency anaemia, pernicious anemia &
leukemia frequently exhibits paraesthesia of oral soft tissues
complicating making a diagnosis when other dental pathosis
is also present in the same area of the oral cavity.

Sickle cell anemia has the complicating factor of bone pain, which
mimics odontogenic pain & loss of trabecular bone pattern on
radiographs which can be confused with radiographic lesions of
endodontic origin.
Multiple myeloma can result in unexplained mobility of teeth.
Radiation therapy to head & neck region can result in increased
sensitivity of teeth & osteoradionecrosis
Trigeminal neuralgia, referred pain from cardiac angina, and
multiple sclerosis can also mimic dental pain.
Acute maxillary Sinusitis- a condition that may mimics tooth pain in
maxillary posterior quadrant. In this situation the teeth in the
quadrant will be extremely sensitive to cold & percussion, thus
mimicking the signs & symptoms of Pulpitis.

Chief complaint is the best starting point for a
correct diagnosis
PAIN is one of the most common chief
complaints encountered

In order to attain a detailed knowledge regarding pain, following
questions may be necessary:
1. Type of pain :
 Grossman has stated Pulpal pain to be of the following two
varieties :
 Sharp, piercing and lancinating -- a painful response usually
associated with the excitation of the A-DELTA nerve fibers. This
pain usually reflects REVERSIBLE state.
 Dull, borinq, gnawing and excruciating-- a painful response
usually associated with the excitation of C-nerve fibers.
 Usually reflects an irreversible state of pulpitis.

2. The duration of pain:
 When the pain is of a shorter duration (1
minute)-Reversible Pulpitis - Excellent chance
of recovery without the need for endodontic
treatment
 Whereas when the pain is of a longer duration,
it is considered to be Irreversible Pulpitis

3. The localization of pain:
 Sharp piercing pain can usually be localized and
responds to cold
 Dull pain usually referred / spread over a larger area
responds more abnormally to heat
 Patients may report that their dental pain is
exacerbated while lying down or bending over
 This occurs because of the increase in blood pressure
to the head, which therefore increases the pressure on
the confined pulp

4. Factors which provoke/ relieve pain:
 Response to a provoking factor (e.g. on
mastication) indicates pulp vitality, but
stimulation causing extended severe pain
suggests irreversible pulpitis.
 Thus pain, which is recorded as the complaint
is considered to conclude an acute or chronic,
reversible or irreversible condition of the pulp.

Characterized by pain which is of a :-
 Shorter duration
 Localized
 May be piercing/ lancinating in nature
 More responsive to cold than heat
 Caused by a specific irritant & disappears as
soon as it is removed

 Abnormal dental pain, which responds to heat
 Which occurs on changing the position of the
head, awakening the patient from sleep
 Dull pain of Longer duration, which occurs
during mastication in a Cariously exposed
tooth

History Slight sensitivity or
occlusal pain
Constant or intermittent pain
Pain Momentary &
immediate, sharp in
nature & quickly
disappears thereafter
Continuous, Delayed onset,
throbbing, persists for minutes to
hours after removal of stimulus
Location of pain May be localized & is
not reffered
Pain is not localized. If it is
localized, its only after periapical
involvement. Pain is reffered.
Lying down No difference Pain increases
Thermal test Responds Marked & prolonged
E.P.T. Early response Early, delayed or mixed response
Percussion Negative Negative in early stages. Later
positive when periapex is
involved
Radiography Negative May show widening of PDL space

Diagnostic procedures in endodontics

The clinician should
look for:
 Facial asymmetry
 Localized
swellings
 Lymphadenopathy
 Changes in color,
bruises/ scars,
similar signs of
disease, trauma or
of any various
treatment.

Begins with a general evaluation of the oral
structures.
The occlusion is checked (for any
derangements if any)
The lips, cheeks, vestibules and mucosa are
examined for any evident abnormalities.
Several tests are employed in order to
determine the condition of teeth and supporting
structures.

Simplest and the easiest of the diagnostic tests
Acc. To Grossman the prime objective of visual &
tactile inspector is evaluation of the “3 C’s” viz:
 Color
 Contour
 Consistency of hard and soft tissues.
Soft tissue:
Color- the normal color of gingiva is coral pink.
Change
from this is easily visualized in inflammatory
conditions.
Contour- change in normal contour (eg, of
scalloped gingiva) occurs with a swelling.
Consistency- On inspection (most commonly
gingiva) appears healthy, firm, resilient, while a soft,
fluctuant or spongy tissue is more indicative of a
pathological state.

Hard tissue:
A similar parameter of the visual and tactile
inspection., ie, of the “C’s’is employed for
the dental tissues as well.
 Color- Normal teeth show life like
translucency & sparkle that is missing in
pulpless teeth which appear more or less
opaque.
Note: This discoloration however could be
due to a variety of other reasons like old
amalgam restorations, tetracycline stains
etc.
 Contour- This examination should also
include the visualization of contours of
affected teeth, such as fractured teeth, wear
facets, improperly contoured restorations, or
altered crown contours as these factors can
have a marked effect on the respective
pulps.
 Consistency- Change in the consistency of
hard dental tissues is related to the
presence of caries, external and internal
resorption

The visual and tactile
inspection is usually carried
out with a mouth mirror,
explorer and a periodontal
probe under dry conditions
with good illumination source.
A general visual examination
of the entire mouth should be
made to ascertain whether the
tooth requiring treatment is a
strategic tooth

Before percussing the involved tooth, instructions
are to be given to the patient to raise his/ her
hand or make an audible sound in order to let the
clinician know when and whether the tooth feels
“TENDER”, “DIFFERENT” or painful on
percussion.
Before percussing the teeth with the handle of the
instrument (a mouth mirror etc), the quadrant of
the involved tooth is percussed using the index
finger with quick blows of low intensity.
The teeth should be tapped (with the index finger)
in a random fashion so that the patient cannot
“anticipate” when the tooth will be percussed
When no response is elicited on digital
percussion, then the handle of an instrument is to
be used/employed.

Percussion is done in both vertical and horizontal
directions.
Change the sequence of percussion in successive
tests to eliminate bias.
The force of percussion should only be strong enough
for the patient to differentiate between a sound tooth
and a tooth with inflamed periodontal ligament.
The proprioceptive fibers in an inflamed periodontal
ligament will, when percussed, help the patient and the
clinician locate the source of pain.

Positive response is indicative of periodontitis (pericementitis)
which could be due to:
 Teeth undergoing rapid orthodontic movement.
 High points in recent restorations.
 Lateral periodontal abscess.
 Partial/total Pulpal necrosis.
Negative response may be seen in cases of
 Chronic periapical inflammation
 Usually
* Dull note- Signifies abscess formation.
* Sharp note- denotes Inflammation.
* Metallic note- Ankylosis.

Employs the usage of the (index finger)
fingertip, supplemented with a light digital
pressure to examine tissue consistency
and pain response.
The importance of this test other than as
an aid in locating the swelling over an
involved tooth, is in determining the
following:
 Whether the tissue is fluctuant and
enlarged sufficiently for incision and
drainage.
 The presence, intensity and location of
pain.
 The presence and location of
Adenopathy
 The presence of bony Crepitus.

To evaluate the integrity of the
attachment apparatus
surrounding the tooth.
Moving the involved tooth
laterally in socket using handles
of two instruments or more
preferably using two index
fingers.
The test for Depressibility is
similar and is performed by
applying pressure in an apical
direction on the occlusal/incisal
aspect of tooth and observing
vertical movement if any.

GROSSMAN AND COHEN:
GRADE I. [First degree] - Noticeable/ barely discernable movement of the
teeth within its sockets.
GRADE-II. [Second degree] - .Lateral/ horizontal mobility within a range of
1 mm or less.
GRADE III [Third degree]-Movement greater than 1 mm or when the tooth
can be depressed into the socket.
MILLER:
 0 - Non mobile/ mobility within physiologic limits.
 1 - Mobility within range of 0-0.5mm.
 2 - Mobility within range of 0.5-1.5mm with lateral movements.
 3 - Mobility more than 1.5 mm with lateral movements and can be
Intruded/depressed into the socket.

Periodontal examination- a must
Furcation involvement.
A lateral canal - portal of entry for
toxins- Pulpal degeneration.
Thermal and electric pulp tests
must be performed along with
periodontal examination to
distinguish between disease of
Pulpal and Periodontal origin.

Assess the state of the pulp.
Based on the Hydrodynamic Theory as postulated by Brannstrom (1963).
 Heat Test
 Cold Test
A response to cold - a vital pulp regardless of whether it is normal or
abnormal- Grossman.
A heat test does not confirm vitality.
An abnormal response to a heat test however exhibits presence of a
pulpal or peri apical disorder requiring endodontic treatment.
when a reaction to cold occurs the patient can quickly point out to the
painful tooth, unlike in a heat test situation where the response could be
localized, diffused or even referred to a different site- Grossman.
The results should be co-related with other tests to ensure validity.

Explain the manner and procedure to the patient and
also the kind of sensation he/she may experience.
First on control teeth- placing the stimuli on the Inciso-
Labial (anterior) surface or the Occluso-Buccal
(posterior) surface.
 Guides the clinician to evaluate the difference in
response, the affected tooth provides.
 Helps the patient understand better the nature of the
stimulus he/she would experience.
Exposed dentinal surfaces and restored surfaces should
be avoided.

Isolation of the quadrant to be tested
The preferred temperature, however, for
performing a heat test (according to Cohen) is
65.5ºC or 150F.

The heat test can be performed using different techniques
such as:
1. Hot air
2. Hot water
3. A hot burnisher
4. Hot gutta-percha
5. Hot compound
6. Polishing of crown with a rubber cup

Isolating the quadrant with the tooth
to be tested.
Cold application can be performed in
any of the following ways viz.
A stream of cold air from a 3-way
syringe directed against the crown of
previously dried tooth.
Use of ethyl chloride spray (which
evaporates rapidly ) absorbing heat
and cooling the tooth surface (-
55ºC).
Ice Stick
CO2 snow

The patient’s response to heat and cold tests are identical
because the neural fibers in the pulp transmit only the sensation of
pain (Hydrodynamic theory -Brannstorm).
There are four possible reactions, that the patient may experience,
1. No response - may be non vital or vital but giving a false-negative
response due to excessive calcifications, immature apex,
recent trauma, patient medication etc.
2. Painful response- which subsides when stimulus is removed
from the tooth- Reversible- pulpitis.
3. Moderate, transient response- Normal.
4. Painful response- which lingers after removal of stimulus-
Irreversible Pulpitis.

•Bender IB et al (1989), J Am. Dent. Assoc : 118; 305-310
•Pulpal Diagnosis, Endodontic Topics 2003, 5, 12-25
•Jack Lin et al (2007) JOE ; 33: 11

Historically, the E.P. tester has been used in dentistry
as early as 1867.
Designed to stimulate a response by electrical
excitation of the neural elements within the pulp.
Does not provide any information regarding the
vascular supply to the tooth.
Considered advantageous when compared with the
thermal tests since the quantitative readings are
obtained which can be compared with that of a later
test (when conducted).

Test should be first described to the patient .
Teeth to be tested should be isolated with cotton rolls, saliva
ejector and air dried.
Check the E.P. tester for proper functioning.
Apply an electrolyte on the tooth surface (Nicholls-colloidal
graphite, Grossman-tooth paste).
Avoid contact of the electrolyte or electrode with any restorations
or the adjacent gingival tissue as this could lead to a false
response.
Retract the patient’s cheek or lip with free hand, away from the
tooth electrode.

* Bender IB et al (1989), J Am. Dent. Assoc : 118; 305-
310
* Pulpal Diagnosis, Endodontic Topics 2003, 5, 12-25

Intensity of stimulus is comfortable to the patients.
The digital display of many E.P.Testers provide
instant, easy and reliable information.
In some E.P. Testers, a red indicator light flashes
on and off when maximum stimulus is reached.
Gives a quantitative reading and can be compared
with the normal reading of control tooth.

Cannot be used on patients having cardiac pace maker.
Some E.P.T equipments are very expensive.
E.P.T is not useful for recently erupted teeth with immature
apex. This may be because the relationship between the
odontoblasts and the nerve fibers of the pulp has yet to
develop (Nicholls).
Recently traumatized teeth cannot be tested.
No indication is given regarding state of the vascular supply
which would give a more reliable measure of the vitality of
the pulp.
Readings from posterior teeth with partially vital pulps may
be misleading.

A. False Positive Responses: When the pulp is necrotic but
patient gives a positive response.
B. False Negative Responses: When the pulp is vital, but the
patient is unresponsive to the E.P.T.
Reasons for False Positive Response:
 Conductor / electrode in contact with a metallic restoration or
gingiva along with the current to reach the attachment apparatus.
 Patient anxiety.
 Liquefaction necrosis-This may conduct the current to the
attachment apparatus and the patient may slowly raise his hand
near the highest range.
 Failure to isolate or dry the teeth
 In multi-rooted teeth where the pulp may be partially necrotic.

Reasons for a False Negative Response:
 Patient heavily pre-medicated with analgesics, narcotics,
alcohol,
tranquilizers.
 Inadequate contact with enamel.
 Recently traumatized tooth.
 Excessive calcification in the canal.
 Recently erupted tooth with an immature apex. This
according to Nicholls, may be because the relationship
between the odontoblasts and nerve fibers of the pulp has
yet to develop.
The results obtained / tabulated through the E.P. T
conducted should not be thoroughly relied upon. These
results should be co-related with those obtained with other
vitality tests such as the thermal tests etc.

Laser Doppler flowmetery
Pulse Oximetery

Restricted to patients who are in pain at the time of the test and
when the usual tests have failed to help identify or localize the
offending tooth.
The objective is to anesthetize a single tooth at a time until the
pain disappears and is localized to specific tooth.
infiltrate the posterior most tooth in the suspected zone.
If pain persists anesthetize the next tooth mesial to it and continue
to do so until the pain disappears.
If the source of pain cannot be differentiated ie. ,maxillary /
mandibular, then mandibular block is implemented.
further localization of the affected tooth is done by an
intraligamentary injection, once the anesthetic has spent itself.
one of the last resorts in localizing the offending tooth.

last resort
The cavity is prepared by drilling through DEJ of an
unanesthetized tooth at a slow speed and without a water coolant.
Sensitivity and pain elicited by the patient is an indication of the
pulp vitality.
A Sedative cement is then placed in the prepared cavity and the
search for the cause of pain may be continued.
On the contrary, if no pain/sensitivity is recorded, the cavity
preparation may be continued until the pulp chamber is reached
and if the pulp is noticed to be necrotic, routine endodontic
treatment could be performed.

Light from a fiberoptic is
applied from the buccal
surface to illuminate the
tooth to detect the
fractured lines when
present

An orangewood
stick is placed on
the occiusal/incisal
aspect (on each
cusp in case of
posteriors) of the
tooth and the
patient is asked to
bite.
To identify the
fractured tooth
/cracked tooth
syndrome.

1. Remove the filling from the suspected tooth and
place 2% Iodine in the cavity preparation.
* The iodine stains the fracture line dark.
2. Mix a dye with zinc-oxide eugenol and place it in the
cavity preparation after filling has been removed.
* The dye will seep out and color the fracture line.
3. Have a patient chew a disclosing tablet after taking
out the filling in the suspected fractured tooth.
* The line will be stained.

Can localize the
endodontic lesion to the
specific tooth.
Aids in the differential
diagnosis between a
periodontal and an
endodontic lesion.
Placing a gutta percha
point through the
sinus/fistula tract and
take a radiograph.

 Provides information on
the extent of caries in to
the pulp
 No. of root canals and
accessories
 The course & shape of
the canals
 Length of the root
 Calcifications
 Resorptions
 PDL status

 Nature of periapical
area & alveolar bone
 Root fractures
 Differentiation of
pathosis
 Location of
perforations

 Post obturation
evaluation
 Evaluate healing
after RCT
 Medico legal
records

State of pulpal health can not
be ascertained
P/A pathology is evident only
after much destruction(33%)
Vertical root fracture can not
be diagnosed
Bony trabculae misinterpreted
for horizontal root #
Extend of caries is usually
less than the actual extent as
is true for P/A pathology

Xeroradiography
Radiovisiography (RVG)
Cone beam computerized tomography (CBCT)
Magnetic Resonance Imaging (MRI)
Ultrasound imaging

REFERENCES:
1. COHEN-Pathways of the Pulp (Ninth Edition)
2. GROSSMAN- Endodontjc Practice (Eleventh Edition)
3. INGLE-Endodontjcs (Fourth Edition)
4. WEINE-Endodontic Therapy (Fifth Edition)
5. Technical equipment for assessment of dental pulp status(Endodontic
Topics 2004, 7, 2–13).
6. Pulpal diagnosis (Endodontic Topics 2003, 5, 12–25).
7. Classification, diagnosis and clinical manifestations of apical
periodontitis(Endodontic Topics 2004, 8, 36–54)

Diagnostic procedures in endodontics

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