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Endodontic diagnosis

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Diagnostic criteria and aids in Endodontics

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Endodontic diagnosis

  1. 1. ENDODONTIC DIAGNOSIS Deepthi P.R. 1st year MDS Dept of Conservative Dentistry & Endodontics
  2. 2. CONTENTS  Introduction  Diagnosis  Diagnostic method  Medical history  Drugs & medication history  Dental history  Subjective symptoms  Clinical observations  Clinical tests
  3. 3. Introduction  Thorough knowledge of other sciences  Diagnosis & Treatment planning  Pain of non odontogenic origin  Accurate database:  Medical & dental history  Clinical examination & relevant tests  Making & interpreting appropriate radiographs
  4. 4. Diagnosis  ‘The art and science of detecting deviations from health and the cause and nature thereof’  Differential diagnosis: ‘The process of identifying a condition by comparing the symptoms of all (or other) pathologic process that may produce signs and symptoms ’ Glossary of endodontic terms. 7th ed. Chicago: American Association of Endodontists;2003
  5. 5. Diagnosis  Inability to test/ image the tissue directly  Indirect interpretation of response to stimuli  Determine teeth free of disease rather than diseased Newton et al. JOE- Volume 35, Number 12, December 2009
  6. 6. Diagnostic method METHODS Pulp testing Palpation Percussion DIAGNOSTIC APPROACHES Bite test Test cavity Staining/ Transillumination Selective anesthesia Radiography Dental history/ Medical history Evaluation of pain signs/ symptoms Newton et al. JOE- Volume 35, Number 12, December 2009
  7. 7. Surgical Sieve Pitt Ford & Rhodes. Endodontics- Problem solving in Clinical Practice • Biographical details • Medical history • Chief complaint • History of present complaint • Dental history • Social history • Extraoral examination • Intraoral examination • Special tests • Radiographs • Diagnosis • Treatment plan
  8. 8. s A sample form used in diagnosis and treatment planning. (Adapted from Krell K, Walton R: Odontalgia: diagnosing pulpal, periapical, and periodontal pain. In Clark J, editor: Clinical dentistry, Philadelphia, 1987, Harper & Row.)
  9. 9. Medical history  Treatment: harmonious with general health  Impact of the patient’s health on the dental operating team  Alterations in the usual course of treatment  Name & contact of physician
  10. 10. Rheumatic fever Potential for SBE after bacteremia Antibiotic premedication:  Artificial heart valves: Same antibiotic coverage: rheumatic fever Pulp extirpation Filing beyond the apex Rubber dam placement Initial appointment/ Surgical appointment Possibilty of going past the apex Periapical lesion
  11. 11. Coronary Artery disease  Physician consultation: anticoagulant  Non surgical treatment preferred  Mild / moderate analgesics  Brief recess: more than one tooth- single appointment  Substernal pain: dressing placed & treatment terminated; referred to physician
  12. 12. Hypertension  Injection of L/A solutions < 30sec/ml  Warm anesthetic solutions: few minutes before injection  Tranquil mood created- minimal mention of complications & failures  Hypnotic premedication: consultation with physician
  13. 13. Hypertension  Avoid G/A & no more than 3 anesthetic carpules  Morning appointments preferred  Night time premedication with early appointments  Total appointment time not > 1 hour  Terminate when patient is stressed
  14. 14. Diabetes  Retarded healing: postop radiographs  Antibiotics: Infection/ surgery 1yearPre op 6 months 2 years1.5 years 3 years
  15. 15. Diabetes  Alteration in blood glucose levels: physician consultation  Epinephrine avoided: Increase in blood glucose levels & tissue sloughs post surgery  Levonordefrin  Barbiturates & sedatives cautiously used
  16. 16. Diabetes  Longer & deeper anesthesia  L/A preferred  Appointments: soon after meals  Differentiate & manage hypoglycemia/ hypoinsulinism • Mepivacaine +Levonordefrin • Propoxyphene+ Procaine +Levarterenol bitartarate
  17. 17. Hepatitis  Resistant to normal sterilization  Intracanal instruments: discarded after use  Avoid drugs detoxified in the liver: Halothane,Erythromycin  Cautious- Paracetamol
  18. 18. Blood diseases  Internal bleeding: L/A administration  Avoid injections: necrotic pulp  Vital pulp: First appt. •Access to the cavity •Dressing Second appt •A week later •Fixed pulpal tissue removed •Dressing replaced Process continued: vital tissue removed Canals enlarged & filled
  19. 19. Blood diseases  Rubber dam: Notches- labial & lingual surfaces  Gingival bleeding: do not treatment without systemic diagnosis  Infectious mononucleosis:  Avoided in acute stage • Pain • Exacerbations • Exaggerated response to drugs
  20. 20. Joint replacement prostheses  Bacteremia  Antibiotic coverage  Painful joint after procedure: orthopedic surgeon consulted  Longer than usual: desirable results  Hypersensitivity states: drugs only when absolutely indicated  Avoid new/ unusual drugs  HIV: transmission avoided- proper asepsis Other serious Diseases
  21. 21. Recent change in weight Weight loss  Dieting  Loss of appetite  Systemic diseases Weight gain  Psychogenic reasons  Hormonal disturbances  Pregnancy  Protect exposed tooth surfaces after endodontic therapy  Salt & water retention
  22. 22. Psychologic problems  Physical problems: tendency towards anxiety  Patients on Tranquilizers/ antidepressants Converted a psychologic condition to physical problem Severe fears & anxieties – treatment difficult • No relief with treatment • Pulpal problem suspected: suspicious oral conditions • Friendly and firm • Instruments: out of sight • Informative booklets • Smooth & painless initial visit
  23. 23. Others Hyperthyrodism  No epinephrine  Increase sedative if needed Ulcers  Avoid aspirin & if on antacids- avoid tetracycline  Use Penicillin V if needed Alcoholic  Cautious with sedatives  Aspirin avoided
  24. 24. Drugs & Medication therapy  Physical condition & effects of medications  Adverse reactions  Questionnaire format  Unaware of Drug’s contents : Mosby’s Drug Consult/ physician  History of allergy: minimum inter appointment time & well monitored
  25. 25. Drugs & Medication therapy  Steroid therapy: intratreatment pain & exacerbations , infections  Appointments: maximum 3 days apart  Vital: 2 sitting & Necrotic: 3 sitting – 1 week period  Surgery- Antibiotic therapy & steroid dose
  26. 26. Drugs & Medication therapy  Aspirin: bleeding after surgery  Avoid- Blood dyscrasia, anticoagulant, renal transplant, gout  Caution- Asthma, Diabetes, Last month of pregnancy  Tranquilizer therapy: unusual reactions to prescribed hypnotics/ narcotics  Physician consulted
  27. 27. Drugs & Medication therapy • CNS stimulant: increase sedative dose • Sulfonamides: avoid procaine Antidepressants: Cautious • GA • Narcotics • Antisialagogue Tetracycline: • Antacids • Penicillin Barbiturates : cautious • Dilantin • Griseofulvin • Steroids
  28. 28. Dental history  Patient’s objective for treatment- clear  Appreciation for dental treatment  Experiences with previous dentist Pain relief Check up Oral systemic relation CosmeticsMasticatory inefficiency
  29. 29. Dental history  Chief complaint & its history  When was it last restored?  Pulp capping/ Pulpotomy/ large restoration in the same  Sharp blow/ accident  Swelling/ gum boil  Drainage
  30. 30. Subjective symptoms  Is the pain still present?  What type? (Sharp/ dull)  Throbbing?  Intermittent/ Continuous?  Aggravated by: cold, heat, pressure, mastication, lying down, sweet, sour?  How long does it last?
  31. 31. Clinical Observations  Extraoral swelling  Lymph node involvement  Intraoral involvement  Fistula  Tooth discoloration  Traumatic injuries: fractures  Deep carious lesion  Recurrent caries beneath a restoration  Extensive restoration  Developmental defects of teeth  Gingival recession
  32. 32. Clinical Tests Diagnostic tests: 1. EPT 2. Thermal tests 3. Percussion 4. Palpation 5. Mobility 6. Periodontal evaluation 7. Occlusal evaluation 8. Radiograph Selective tests for Difficult Diagnostic Situations: 9. Test cavity preparation 10. Anesthetic test 11. Transillumination 12. Biting 13.Staining 14. Gutta percha point tracing with radiograph
  33. 33. Extraoral examination  External facial form & features  Fistulae, erythema, pallor  Neurologic examination: motor function, sensitivity, movement  Lymph nodes: inflammatory, infectious, tumor like disorders
  34. 34. Intraoral examination Soft tissue examination:  Swelling/ fistula
  35. 35. Intraoral examination  Crown discoloration: non vital pulp, removal of discolored dentin, use of chlorinated soda  Deep carious lesions/ fractures: visual examination & probing
  36. 36. Percussion test  Simple, but useful  Inflammatory condition of the apical periodontium  First clinical indications of apical periodontitis
  37. 37. Percussion test  Symptomatic apical periodontitis: more sensitive  Pulpal diseases: not reveled unless apical periodontium is involved  Periodontal/ endodontic etiology, occlusal trauma, combination with marginal periodontitis  Horizontal percussion
  38. 38. Percussion test  Firm digital pressure/ handle of instrument like mouth mirror: tap in a vertical direction  Patient bite on Tooth Slooth/ Cotton swab  Several teeth repeatedly  Random order
  39. 39. Palpation  Vestibular region: apical region of the root tips  Tenderness, swelling, fluctuation, hardness, crepitation  Tip of index finger  Usefulness increase with skill & clinical experience
  40. 40. Mobility  Moving in a buccal- lingual direction  Index finger on the lingual surface & lateral force applied with instrument handle from buccal surface  Using two fingers
  41. 41. Mobility Miller’s index:  Class 1- First distinguishable sign of greater- than- normal movement  Class 2- Movement of the crown as much as 1mm in any direction  Class 3- Movement of the crown more than 1 mm in any direction and/or vertical depression/ rotation of the crown in its socket
  42. 42. Periodontal probing  Endodontic & periodontic lesions mimic each other concurrently  Record probing depths: periodontal health & prognosis  Entire circumference probed
  43. 43. Periodontal probing Narrow isolated probing defects:  Periodontal disease  Sinus- like trap following periapical pathosis  Vertical groove defect  Cracked teeth  Vertical root fractures  External root resorption
  44. 44. Tests for Cracked Tooth Syndrome Transillumination  Fiberoptic light  Coronal cracks/ vertical root fractures  Minimal background lighting  Light placed on varied surfaces of coronal tooth structure/ root after flap refection
  45. 45. Transillumination  Light traverses fracture lines- visually detected  Fractured Segment near the light appears brighter
  46. 46. Dye staining  Dye penetrates fracture line  Demonstrates fractures  Apply – internal surfaces of cavity preparation/ access opening  Leave it in place for a week  Iodine/ methylene blue dye
  47. 47. Dye staining 3 methods: Remove restoration:  Direct revealing of fracture line  Dye incorporated into ZOE mixture & placed  Patient chews on disclosing tablet Bessner & Ferrigno. Practical guide to Endodontics
  48. 48. Bite test  Wooden stick- opposing teeth  Tooth slooth  Patient bites down & pain elicited upon release  Rubber dam sheet- cracked cusp flexes
  49. 49. Pulp tests  Major & essential part of diagnostic process  Reproduce patients symptoms, diagnose diseased tooth & disease  2 independent diagnostic test results Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  50. 50. Pulp tests  *Ideal technique: non invasive, painless, standardized, reproducible, reliable, inexpensive, easily completed & objective *Chambers. 1982 Pulp sensibility tests • Thermal tests • Electric pup tests • Test cavity Pulp vitality tests • Laser doppler flowmetry • Pulse oximetry • Tooth temperature measurement
  51. 51. Pulp sensibility tests  Pulp nerve fibers respond – external stimulus  Thermal/ Electrical / Direct dentine stimulation  Do not indicate the health status & unreliable responses Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  52. 52. Pulp sensibility tests  No indication of vitality: intact vasculature  Correlation between test results & necrotic pulps only*  Assess whether necrotic or not & does not quantify the degree of disease  Useful : identifying diseased tooth *Seltzer et al.1963, Tyldesley & Mumford 1970, Dummer et al, 1980
  53. 53. Pulp sensibility tests Preferred sequence:  Tests repeated after 1’ recovery time  Thermal tests: no method to assess how responsive the tooth is or to compare with previous result  EPT: numerical display- not essentially reproducible Disease free contralateral teeth Opposing teeth Presumably healthy teeth- same quadrant Most suspicious tooth
  54. 54. Rationale of the tests  Sharp, non lingering pain- application of thermal stimulation: normal  A - 25% stimulus required to activate C fibers* *Virtanen 1985, Hargreaves & Goodis 2002
  55. 55. Thermal tests- Rationale  Sensory response: not by temperature changes in receptors  Hydrodynamic movement of fluid: dentinal tubules- A fibers  Cold- faster A fibers: sharp localized pain  Heat- slower C fibers: dull long lasting pain Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  56. 56. Electric Pulp Test - Rationale  Current sufficient to overcome the resistance of enamel & dentine- stimulate A fibers  Sensation felt with gradually increasing level of current: pulp responsive/ partially alive  *Ionic shift in tubules local depolarization action potential Pantera et al. 1993
  57. 57. EPT- Rationale  A fibers: brief sharp sensation/ tingling  *No blood flow- pulp becomes anoxic & A fibers cease to function *Pitt Ford & Patel 2004
  58. 58. Indications 1.Pain in the trigeminal area; referred pain 2. Periodical monitoring of teeth after trauma  1-8 weeks lapse before normal response  EPT: reliable after trauma** *No response Response : Recovery Repetitious response :Healthy pulp Response No response: Degeneration No response persistent: Necrotic pulp **Ingle et al 2002,*Bhaskar & Rappaport 1973
  59. 59. Indications 3. Assessment of pulpal health before restorative procedures  potential prosthetic abutment 4. Pulp preservation procedures & extensive restorations 5. Differentiate periapical radiolucencies from normal anatomical structures & non odontogenic lesions Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  60. 60. Indications 6. Predict potential anesthetic problems & evaluation of analgesics  Cold test: assess pulpal anesthesia  Preoperative pulp-test performed  Traditional parameters verified  Retested with the same test  Prepared for treatment & level of anesthesia screened Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  61. 61. 7. Pulp status of transplanted teeth
  62. 62. Indications 8. Le Fort type fractures/ osteotomies  Normal: 7-11 months after surgery
  63. 63. Limitations 1. Subjective; measure only nerve supply 2. Thermal tests: not effective in substantial secondary dentine formation 3. Unreliability of tests: Immature apices, traumatic injuries, more subjectivity in the young 4. No correlation with the histologic status (Contrasting results: Hill, 1986) Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  64. 64. Limitations 5. Difficult to administer & inconclusive in children 6. Weaker response- aged pulp 7. Extensive restorations, pulp recession, pulp calcification 8. Lack of reproducibility Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  65. 65. Interpretation- Diagnosis  Immediacy, intensity & duration of response  Outcome: never certain  No particular response- unique to specific pathologic states Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  66. 66. Clinically Normal pulp  Mild to moderate transient response to cold & electrical stimuli  Response subsides in few seconds on removal of stimulus  Do not usually respond to heat tests
  67. 67. Reversible pulpitis  Thermal stimuli (cold)- sharp pain  Subsides as soon as the stimulus is removed/ in few seconds
  68. 68. Irreversible pulpitis  Thermal changes (cold): sharp pain , dull prolonged ache- last upto an hour or so  Valuable: stimulus as reported by patient applied & pain reproduced & assessed  EPT: not of value
  69. 69. Pulp necrosis  Histological state not determined  Significant relation between lack of response & pulp necrosis  No response with EPTs & thermal tests  No indication of infection expected from these
  70. 70. Pulp necrobiosis  Difficult to diagnose  History : pulpitis  Pulp tests: necrosis  Vague response to EPTs, cold tests
  71. 71. Periapical conditions Acute apical periodontitis  Maybe associated with pulpitis  Pulp status assessed before treatment Acute apical abscess  Negative Lateral periodontal abscess  Positive Chronic apical periodontitis  Sequel of infected canal system
  72. 72. False responses False negative results: Normal pulps that do not respond to tests  Calcification: no response to cold; may respond to high value of current in EPT  Premedication  Recent trauma  Immature apex  RCT teeth: not expected to respond Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  73. 73. False responses  Extensive restorations  Pulp protecting bases  High pain threshold  Activation of fixed orthodontic appliances  Psychotic disorders  Defective EPT device/ discharged batteries/ poor electrical contact
  74. 74. False responses False positive results: Necrotic pulps responding to tests  Conduction of current to adjacent gingival & periodontal tissues (avoided with reasonable current strength & proper techniques)  Moist gangrene, partially necrotic tissue, infected pulp  Breakdown products of localized necrosis
  75. 75. False responses  Calcified tooth structure conducting to tissue apical to an area of necrosis  Current conducted to adjacent teeth through metallic restorations (avoided by rubber dam / celluloid strips between teeth)  Inflamed pulp tissue in one canal of a multirooted teeth with other canals & chamber necrotic  Anxious/ young patient
  76. 76. False responses  More common with EPT than cold test  EPTs: all teeth; cold tests: multirooted teeth  EPT: rare false negative, if more than one surface used  Cold test: sometimes, only cervical area responds
  77. 77. Value of diagnostic tests  Precision: ‘Tendency of repeated measurements on the same sample to yield the same result’  Variability: Lack of precision  Accuracy: The extent to which a test correctly classifies patient’s response  Sensitivity: The ability of the test to detect the disease in patients who actually have the disease Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  78. 78. Value of diagnostic tests  Specificity: The ability of a test to detect the absence of a result  Positive predictive value: The probability that a positive test result actually represents a disease positive tooth  Negative predictive value: The probability that a tooth with a negative test result is actually free from the disease
  79. 79. Value of diagnostic tests  Heat: relatively high sensibility; but least accurate being the least specific  Cold test: more accurate than EPT
  80. 80. Thermal tests  Often inappropriately referred to as ‘Vitality tests’  More reliable than EPT  Inexpensive & easy-to- use equipment  Patient’s pain reproduced
  81. 81. Thermal tests • Initial cold sensitivity • Heat sensitivity- continued pulp deterioration • Disappearance of cold sensitivity • Cold stimuli might relieve heat induced pain
  82. 82. Damage to hard & soft tissues of the tooth  Heat test: more potential to injure  Tissue freezing: -100c for 5-20’  Intracellular ice crystal formation & ischemic necrosis following vascular injuries  -220c lowered pulp temperature to 110c: caused no damage (Langeland et al, 1969)
  83. 83. Damage to hard & soft tissues of the tooth  Conflicting reports: Dry ice inducing enamel cracks  Delayed cold transfer process: Cold stimulus applied to necrotic pulps under a bridge- felt by adjacent tooth  ‘Film boiling’/ ‘ Leidenfrost phenomenon’: Insulating layer of CO2 gas around dry ice, if it falls into mouth
  84. 84. Cold tests Ice sticks  0oC temperature  Not accurate: adult posterior teeth  Secondary/ reparative dentin deposition  Testing under crowns/ splints  Application- 5s : reliable & valid  Disadvantage: less effective stimulation Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  85. 85. Cold tests  Freezing water- hypodermic needles’ plastic cover/ L/A cartridges  Held using gauze  Cervical (Ruddle 2002),or middle (Cohen & Hargreaves 2006),exposed metal surface  Quickly move back & forth
  86. 86. Cold tests  Begin with most posterior tooth  Cotton pellet placed just distal to the tooth  Contact with adjacent gingiva or nearby teeth: false responses
  87. 87. Cold tests Refrigerant sprays  Convenient & easiest to use  Ranks just behind dry ice  Dichlorodifluoromethane (DDM)  Tetrafluoroethane (TFE)  Propane butane mixture (PBM)  -20oC to -50oC
  88. 88. Cold tests  DDM: Freon-12  Compressed spray: Endo-Ice (-50oC)  DDM- production prohibited due to environmental concerns  Greater decrease in temperature than dry ice & ethyl chloride  Saturated cotton pellet:  Multiple teeth : less effeicienty tested
  89. 89. Cold tests  TFE: Green Endo-Ice (-26oC)  No ozone depletion potenial  Easy to use & rapid results  Sprayed onto cotton pellet & applied to middle third facial surface  5s or until pain  Equivalent to dry ice & even in restored teeth
  90. 90. Cold tests  PBM- Endo-Frost (-50oC)  30-50% Propane, 30-50% butane & 30-50% isobutane  Nontoxic cold spray- freeze cotton pellets & rolla  Similar intrapulpal temperature decrease
  91. 91. Cold tests Carbon di oxide snow/ Dry Ice  Charles Thilorier -1835  Dentistry: Back -1936  Apparatus modified by Obwegser & Steinhauser 1963: pencil like form  -78oC; -56oC direct application  Rapid response: <2 s Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  92. 92. Cold tests Mechanism:  PDJ temperature reduced to <2oC  Hydrodynamic theory  Enamel expansion / contraction & acts as temperature transfer medium (Linsuwanont et al 2007)
  93. 93. Cold tests Technique  CO2 released into special tube inside plexiglass container: snow  Compacted with a plugger: pencil/ stick  Middle third of the facial surface of crown: 2-5seconds or until pain
  94. 94. Cold tests Advantages  Accurate, reliable, consistent, fast & uncomplicated  1-2 minutes- without isolation  Does not affect adjacent teeth  Intense reproducible response  Greater accuracy than EPT
  95. 95. Cold tests  Full coverage restorations  More reliable after trauma  Under splinted abutments  No false positive in necrosis  Sustained lingering response: early puplpitis  Fixed orthodontic treatment
  96. 96. Cold tests Disadvantages  Not effective with calcified pulps  More expensive than ethyl chloride/ ice sticks  More dependable results than ethyl chloride/ ice (Fuss et al 1986, Andreasen 1976)
  97. 97. Cold tests Ethyl chloride spray  Chloroethane (-12.3oC)  Colorless, flammable gas  Skin refrigerant, mild topical anesthetic  CNS depressant  Better than EPTs & heated GP  Not used: less effective than dry ice/ DDM Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  98. 98. Cold tests Cold water bath  Tooth/ group of teeth : isolated with rubber dam  Iced water syringed onto tooth  Effective: simultaneous bathing of entire crown  Effective with full coverage restorations  Better than ice sticks & no armamentarium than rubber dam  Time consuming
  99. 99. Heat tests  Heat: fluid expansion- A fibers  Inflamed pulp: C-fibers; lasting response  Acutely inflamed/ partially necrotic pulp  Low diagnostic accuracy- not used as single method
  100. 100. Heat tests Heated GP ( Grossman’s method)  Warmed sticks of GP (120-140oC)  Dry tooth surfaces & surrounding areas with cotton rolls  Iight coating of petroleum jelly  GP stick warmed over flame till glistening Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
  101. 101. Heat tests  Difficult to control temperature  Concerns of damage to healthy pulp : not with <5 s application (Rickoff et al 1988)  Reproducible results not obtained  Lack of response in bulkier teeth  Less consistent stimulus  Limited value: posterior teeth & under splints , temporary crowns
  102. 102. Heat tests Warmed hand instruments  Popular, not very reliable & poorly assessed method  Heated over a flame, held close to buccal surface; without actually touching  Not reproducible  Difficult to control temperature & safety problems
  103. 103. Heat tests Electrical heat sources  Touch ‘N Heat/ System B- 150oC  Inserts: Hot Pup Test Tip  Continuous heat mode- intensity set  Tooth surface lubricated Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010 Castelucci. Endodontics Vol.1
  104. 104. Heat tests Frictional heat  Rubber cup- prophylaxis  Buccal surface  Best, easiest & safest  Gold crown  Seldom used today
  105. 105. Heat tests Hot water bath  Similar to cold water bath  Temperature gradually increased  Begin with most posterior and proceed until positive response  Greater thermal change  PFM crowns  Time consuming & patient cooperation
  106. 106. Remember..  Inform patient of the nature of tests  Hand signals  Stimulus removed after 5-6 s  Refractory period after cold test  Cervical aspect (Petyers eta 1994, Ruddle 2002)  middle third of buccal/ palatal aspect (Cohen & Hargreaves 2006)
  107. 107.  Incisal- anterior & incisal aspect of mesiobuccal cusp: posterior (Trope & Debelian 2005)  Ideally be tested on all surfaces  Several adjacent, contralateral & opposing teeth tested  Individual perception  Should not bias
  108. 108. Electrical pulp tests  Direct stimulation of pulp nerve fibers  Unreliable: necrotic & disintegrating pulp tissue leaves electrolytes in pulp space  Adequate stimulation, appropriate technique, careful interpretation  AC or DC; Pulsating DC: 5-15ms best nerve stimulation  Rate of current increase, strength duration & frequency
  109. 109. Electrical pulp tests  Benchtop style digital EPT  Handheld style digital style EPT  Handheld style analog EPT
  110. 110. EPT  Monopolar/ Unipolar and Bipolar  Mains power connection & Batteries  Mid-1950’s: Bipolar- one electrode to the other through tooth or one handheld  Monopolar: anode on the lip & cathode on the tooth  Comparative studies: conflicting results
  111. 111. EPT & Histology  No correlation between positive EPT & histological status*  Presence of sensory fibers that can respond to electrical stimulus  Quantification or comparison of responses- not conclusive  Cannot assess vitality  Negative response- necrosis Reynolds 1966, Mumford 1967b, Matthews et al 1974b, Cooley & Robinson 1980
  112. 112. Technique of use  Technique sensitive  Removal of supragingival calculus  Exterior surface dried & rubber dam placed  Insulation of proximal restorations  Probe checked on skin- ensure current flow
  113. 113.  Circuit completed  Electrode coated with suitable medium  Middle third of facial surface  Direct contact necessary: small tip on restored teeth  Rheostat: 1-10, 1-15, 1-80  Slowly increased: more accurate
  114. 114.  Procedure explained  Tingling/ warm/stinging/ full/hot  Shift tip position: if no response  Tested 2 0r 3 times: ensure consistency  Testing switched off / changing order; eliminates bias & anxiety driven responses
  115. 115.  Full porcelain/ gold crowns  Cavity prepared through restoration without L/A until dentin  If no response: EPT probe on dentin  Rubber dam piece: insulate tip from metal  Highly different response: control tooth
  116. 116. Circuit completion  Use without rubber gloves  Lip clip: lose retentiveness & reliable contact  Touch the probe handle with finger: gives patient control  Modify EPT with metal rod
  117. 117.  Roll down dentist’s gloves: contact with wrist & patient’s face  Custom made patient held contact device  Stabilization groove cut on the probe engaged by current conducting sleeve: not recommended
  118. 118. Variations in reading/ False response Failure to complete the circuit  Equipment problems  Probe placement  Interface media Patient related factors  Tooth characteristics  Restored teeth  Dentition  Supporting tissues  Apex maturation  Repeated trials  Psychological state  Physiological state
  119. 119. False positive response  Necrotic pulp responds to testing.  Stimulation of adjacent teeth/ attachment apparatus  The response of vital tissue in multirooted tooth with pulp necrosis in one or more canals  Patient interpretation: subjectivity William T. Johnson. Colour Atlas of Endodontics
  120. 120. False negative response  Vital pulp that does not respond to stimulation  Inadequate contact with the stimulus  Tooth calcification  Immature apical development  Traumatic injury  Subjective nature of the tests  Elderly patients – regressive neural changes  Analgesics for pain  Traumatic injury
  121. 121. Limitations of EPT  No information on health status/ integrity  Unreliable for immature teeth  Not suitable with full coverage restorations  Chances of ventricular fibrillation
  122. 122. Test cavity  Non localized, acute diffuse radiating pain  Definitive diagnosis: impossible  Cavity prepared in the tooth: concealed position without anesthesia  Patient apprised of what to expect & how to respond
  123. 123. Test cavity  Response: cavity preparation stopped & restored again  No response: endodontic access cavity continued  Low speed handpiece & small bur recommended  Full crown restorations & margins contacting gingival tissue
  124. 124. Test cavity  Young teeth: immature roots- invasive nature questioned  Unreliable; response even in necrotic pulp  Response unreliable: anxiety  Invasive & irreversible  No further information than thermal & EPT  Not justified in modern practice
  125. 125. Laser Doppler Flowmetry Jafarzadeh .IEJ, 42, 476- 490,2009  Optical measuring method- number & velocity of particles conveyed by a fluid flow to be measured  Laser light is transmitted to the pulp by means of a fiber optic probe
  126. 126. Laser doppler flowmetry  Scattered light from the moving RBCs in the circulation will be frequency-shifted, while those from the static tissues remain unshifted.  Reflected light composed of Doppler shifted and unshifted light is returned to photodetectors  Detected & processed -signal measure of the blood flow in the dental pulp Jafarzadeh .IEJ, 42, 476-490,2009
  127. 127. Laser doppler flowmetry  Not useful in teeth with crowns and large restorations  Detect only the coronal blood flow of the pulp, which may not relate to the actual blood flow on the linear scale. Advantages:  Painless diagnosis as compared to thermal & electric pulp tests  Diagnosis of immature or traumatized teeth
  128. 128. Pulse Oximetry  Effective, objective oxygen saturation monitoring technique - intravenous anesthesia  Consistently determined the level of blood oxygen saturation of the pulp- pulp vitality testing Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009
  129. 129. Pulse Oximetry  Correlation between pulp and systemic oxygen saturation readings (Schnettler and Wallace1991)- definitive pulp vitality tester  Biox 3740 Oximeter (Kahan et al 1996)  Custom-made Pulse Oximeter sensor holder (Gopikrishna et al 2006) Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
  130. 130. Pulse Oximetry  Probe containing two LEDs: red light- 660 nm & infrared light (900–940 nm)  Measures absorption of oxygenated and deoxygenated Hb  Received by a photodetector diode connected to a microprocessor.  Relationship between the pulsatile change in the absorption of red light & infrared light : assessed by the oximeter + known absorption curves for oxygenated and deoxygenated hemoglobin, Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009
  131. 131. Pulse Oximetry Indications:  Recent trauma  Primary & immature permanent teeth  Patient monitoring: sedation Limitations:  Intrinsic interference: venous blood & tissue constituents, acidity,CO2  Extrinsic interference  Well adapting sensor  Hb bound to other gases  Extensive restorations Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009
  132. 132. Pulse Oximetry  70%- 100% accuracy  Inverse correlation between saturation values & EPT readings (Radhakrishnan et al 2002)  More sensitive & specific compared to cold tests & EPT (Gopikrishna et al 2007) Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009
  133. 133. Dual Wavelength Spectrophotometry  Method independent of a pulsatile circulation  Measures oxygenation changes in the capillary bed rather than in the supply vessels  Detects the presence or absence of oxygenated blood at 760 nm and 850nm.  Advantage: Uses visible light that is filtered and guided to the tooth by fibreoptics Divya et al.Contemporary Diagnostic AIDS in Endodontics”. Journal of Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue 06, February 10
  134. 134. Ultraviolet light/Fiberoptic Fluorescent Spectrometry  Fluorescence  Vital teeth fluoresce normally; necrotic & RCT teeth do not –Foreman  Lighting in the operatory fully suppressed  Patient & staff wear suitable protective goggles  Fluorescence from the pulp -substantially lower than the healthy and decayed dentin fluorescence.  Healthy and decayed dentin patterns differentiated Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
  135. 135. Photoplethysmography  Optical measurement technique : blood volume changes in the microvascular bed of tissue.  Light source to illuminate the tissue & a photodetector to measure the small variations in light intensity associated with changes in perfusion Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
  136. 136. Anesthetic test  L/A: painful area  Block/ infiltration/ intraosseous  Vague location of pain  Non odontogenic pain:Myocardial infarction  Differentiating between arches  PDL- identify source of pulpal pain.
  137. 137.  Dentin sterilizing : Silver nitrate, phenol, eugenol & desensitizing substances  Cleansers: Alcohol, chloroform, H2O2, various acids  Restorative materials & liners Besner, Ferrigno. Practical Endodontics- A Clinical Guide
  138. 138. Tooth surface temperature  Fanibunda: pulp circulation maintains tooth temperature  Cholesteric crystals- 10% solution in chlorinated hydrocarbon solvent(Howell et al)- non vital: lower temperature  Thermistor: vital & RCT teeth- with and without gold crowns (Banes & Hammond)  Consistent (Stoops & Scott) Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
  139. 139. Tooth surface temperature  Electronic thermography: Infrared sensor, control unit, thermal image computer, software, color monitor, printer  Differences in deep & superficial areas- not sensitive  Hughes Probeye 4300 thermal video system: sensitive to measure 0.1oc  Adjunct to other diagnostic tests
  140. 140. Patient temperature  Baseline temperature: follwed up  Patient is improving/ worsening  >1000oF : systemic response to infection
  141. 141. Ultrasound  Compliment conventional radiography  High resolution, 3D images- inner macrostructure of the tooth  A transducer (a crystal containing probe), a coupling agent & software  Detect cracks in a simulated human tooth  Detect vertical root fractures – vital & nonvital teeth Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
  142. 142. Ultrasonic Doppler Imaging  Blood circulation detected  Distinguish vital teeth from root- filled teeth: blood flow parameters, waveform, sound  Promising tool- traumatically injured teeth  Power Doppler associated with color Doppler – improved sensitivity to low flow rates Yoon et al. JOE- Volume 36, No.3, March 2010 Vital tooth Non vital tooth
  143. 143. Optical Reflection Vitalometry  Preliminary report-1997 (Oikarinen et al)  Noninvasive method  The pulse of the pulp/oral mucosa.  Yet to be clinically accepted & commercially available. Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
  144. 144. Evaluation of Sensibility Tests  Thermal test: Endo Ice & EPT- evaluated  Endo Ice- 0.904 accuracy & EPT- 0.75  Age group 21-50 & vital teeth: more accurate response to cold test  Jespersen et al. JOE- Volume 40, No.3, March 2014
  145. 145. RADIOGRAPHY-Little value : assess pulp status  Presence & extent of carious lesions  Vital pulp therapy  Calcifications  Resorptions  Periradicular radiolucencies  Tracing fistulous tracts  Thickness of PDL  Periodontal disease  Root & pulp space anatomy  Previous RCT
  146. 146.  Bitewing: pulp chamber  Eccentric ray alignment Beer, Bauman, Kim. Color Atlas of Endodontology
  147. 147. Digital radiography  Variables in diagnostic quality of conventional radiography- controlled  Image- enhanced, colorized and useful patient education tool
  148. 148. Cone Beam Volumetric Tomography  First used in dentistry- Mozzo P et al 1998  Proximity to anatomic structures  Root canal anatomy
  149. 149. Diagnosis: never based solely on radiographic finding
  150. 150. Thank you!!!!
  151. 151. References  Endodontic therapy – Weine  Endodntics6- Ingle et al  Cohen’s sPathways of the Pulp- 10th ed  Color Atlas of Endodontics- William T. Johnson  Endodontics- Problem solving in Clinical practice- Pitt Ford  Practical Endodontics- A clinical guide. Bessner & Ferrigno
  152. 152.  Pocket Atlas of Endodontics- Beer  H. Jafarzadeh & P. V. Abbott. Review of pulp sensibility tests. Part I: general information and thermal tests. IEJ, 43, 738- 762, 2010  Yoon et al. JOE- Volume 36, No.3, March 2010  Jespersen et al. JOE- Volume 40, No.3, March 2014

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