seminar

2. EXAMINATION, EVALUATION,
DIAGNOSIS AND TREATMENT
PLANNING IN ENDODONTICS
Presented by :-
Dr. Shruti Mishra
PG 1st year
Dept. of Conservative
Dentistry
GUIDED BY:-
DR. MANOJ CHANDAK
DR. PRADNYA NIKHADE
DR. AJAY SAXENA
DR. ANUJA IKHAR
DR. GOPAL TAWANI
DR. ADITYA PATEL
DR. NEELAM CHANDWANI
DR. NIKHIL MANKAR
DR. NEHA SHUKLA

3. CONTENTS
• Introduction
• Diagnosis
• Diagnostic methods
• Medical history
• Dental history
• Clinical examination
• Clinical tests
• Newer trends
• Radiography
• Prognosis
• Treatment planning

4. RECAP

5. INTRODUCTION
Correct treatment begins with correct diagnosis.
Grossman 11th edi.

6. • Providing a wrong treatment plan could intensify a patient’s symptom
and make it even more difficult to arrive at a correct diagnosis.
• The Hippocratic oath counsels
“first, do not harm.”

7. • Stedman’s medical dictionary describes Clinical Diagnosis as
“the determination of the nature of a disease made from a study of
the signs and symptoms of a disease”.
• Collection of information, history , signs and symptoms , a thorough
clinical examination , and objective testing are mandatory prior to
recommending and initiating treatment.

8. • Symptoms : these are units of information sought in clinical diagnosis.
“they are defined as phenomena or signs of a departure from the normal and
indicative of illness.”
• Symptoms can be classified accordingly :-
a)Subjective symptoms b)Objective symptoms

9. • Sensitivity-it is defined as the ability of the test to identify the teeth that
are diseased.
• Specificity – it is defined as ability of the test to identify teeth without
disease.

10. Subclinical initial lesions in a dynamic
state of progression/regression
Lesions detectable only with additional
diagnostic aids
Clinically detectable enamel lesions
with intact surfaces.
Clinically detectable cavities
limited to enamel
Clinically
detectable lesions
in dentin
Lesions
in the
pulp
Iceberg of dental caries
D4
D3
D2
D1
CLINICAL
EXAMINATION
CLASSICAL
EPIDEMIOLOGICAL
SURVEYS
PREVENTIVE
AND OPERATIVE
CARE ADVISED
PREVENTIVE
CARE ADVISED
NO
ACTIVE
CARE

11. DIAGNOSTICMETHODS
Dental history/
medical history
Evaluation of
pain/symptoms
Methods
Palpation
Percussion
Pulp testing
DIAGNOSTIC
APPROACHES
Bite test
Test cavity
Staining/ Transillumination
Selective anesthesia
Radiography

12. HISTORY TAKING
• The first step in arriving at a diagnosis is the recollection of the patient’s signs and
symptoms, the past as well as the present.
• A complete history will often modify endodontic treatment and may even determine
the total treatment.

13. 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.)

14. CASE HISTORY
• Biographical details
• Chief complaint
• History of present
illness
• Past medical history
• Social history
• Extra oral examination
• Intraoral examination
• Special tests
• Radiographs
• Diagnosis
• Treatment plan

15. CHIEF COMPLAINT
• The chief complaint of the patient is the reason the patient is seeking
care.
• It should be always documented in patient’s own words.
• This verbal description of the problem is aided by hand gestures and the
patient pointing to a general area of discomfort.

16. PRESENT DENTAL ILLNESS
• It should determine the severity and the urgency of the problem.
• Open ended questions should be asked to the patient rather than closed ended.
• Questions should start from “how”, “when”, “where”& “what”.

17. • History of recent dental treatment.
• History of trauma should be asked before determining the course of
treatment.
• The character of pain, severity , aggravating and relieving factors and
medications the patient is taking to alleviate the symptoms

18. DENTAL HISTORY INTERVIEW
• The dental history is divided into five basic directions of questioning:
localization, commencement, intensity, provocation and attenuation and
duration.
Localization :-
1. Can u point to the offending tooth?
This will point towards the events that might have caused any particular
pathosis in this tooth.

19. Commencement :
2.When did the symptoms first occur?
Initiating event:---Spontaneous in nature
-Might have begun after a restoration
-Trauma may be the etiology
-Biting on a hard object
-May have occurred concurrently with other symptoms.
(sinusitis, chest pain or headache).

20. Intensity
3.How intense is the pain?
Helps to quantify the pain of the patient.
1. The intensity level will affect the decision to treat or not to treat the
tooth with endodontic therapy.
2. Pain is now considered a standard vital sign, and documenting pain
Intensity (0-10) provides a baseline for comparison for treatment.

21. Provocation and attenuation
4.What produces or reduces the symptoms?
• Mastication and locally applied temperature changes account for the
majority of initiating factors that cause dental pain.
• Drinking something cold- causes pain.
• Chewing or biting on hard object is the only stimulus.
• Pain only reproduced from “release on biting”.

22. • Symptoms reduced by bathing the tooth in cold water.
• The type of drugs patient has taken for the pain(narcotics or non
narcotics)
• Important to know what drugs have patient taken in the previous 4-6 hrs.

23. Duration :-
5.Do the symptoms subside shortly, or do they linger after they are
provoked?
• The duration of the symptoms after a stimulating event should be
recorded to establish how long the patient felt the sensation in terms of
seconds or minutes.
This completes the dental history interview.
This will help to formulate an objective diagnostic evaluation.

24. PAST MEDICAL HISTORY
• Patients need to share their medical problems with clinicians so the data
can be used in planning treatment.
• Health history is one of the most important steps in diagnosis and
treatment planning.
• Treatment: harmonious with general health.
• Alterations in the usual course of treatment.
• Name & contact of physician.

26. CARDIOVASCULAR DISEASES
• Patients -vulnerable to stress.
• Consult physician before starting the treatment.
• Unstable angina or MI(past 30 days)- elective care is postponed.
• Ischemic heart disease – potential threat from local anesthesia.
• A safe dose of 0.036mg epinephrine (2 cartridges containing
1:100,000 epinephrine) at one appointment should be given to the
patients with intermediate risk factors.

27. CARDIOVASCULAR DISEASES
• Use of prophylactic antibiotics in patients with infective endocarditis.
• Stress reduction strategies will minimize the risk of serious cardiac
sequelae.
Diazepam 2-5 mg the night before or 2- 5 mg 1 hour before the procedure.
• The physician should be consulted before making the final decision.

28. CARDIOVASCULAR DISEASES
• Before endodontic procedures:- rinse with antimicrobial agent 5 or 6
times before expectorating.
• Patients with acute periapical abscess- administer 2g of penicillin orally
and wait for 1 hour before establishing drainage through the canal.
• Use semi-supine or upright chair position for patient’s comfort.

29. HYPERTENSION
• Management of stress and anxiety
• For very anxious patients-small dose of diazepam (5 mg) or
shorter-acting benzodiazepines, such as oxazepam (30 mg) the
night before and 1 hour before the dental appointment.
• Total appointment time not > 1 hour.
• Terminate when patient is stressed.

30. Category optimal SBP(mm Hg)
<120 and
DBP(mm Hg)
<80
Normal <130 and <85
High normal 130-139 or 85-89
Hypertension
Stage 1 140-159
or
90-99
Stage 2 160-179 or 100-109
Stage 3 >180 or >110
Classification of bloodpressure findings

31. HYPERTENSION
• Injection of L/A solutions < 30sec/ml without adrenaline.
• For stage 1 HTN- two 1.8 ml cartridges of lignocaine with (1:100,000)
adrenaline (0.036 mg) is safe.
• For stage 2 HTN- LA with adrenaline should be used with precautions..
• Monitoring of blood pressure before and after the administration of local
anesthesia.
• Morning appointments and less in number.

32. HYPERTENSION
• Nitrous oxide may be beneficial in controlling anxiety.
• Use of oral sedatives the night before or during the procedure
(pharmacosedation) is also considered as effective.
• The risky patients should be advised to seek medical attention,
during the dental treatment.

33. DIABETES
• The dentist should be aware of the patient’s recent glycated
hemoglobin values.
• HbA1c < 8% relatively good glycemic control; >10%  poor
control.
• When the level of control of diabetes is not known, consult patients
physician and the treatment should be just limited to palliation.

34. • In patients with good glycemic control before starting any procedure,
verify that the patient has taken medication and diet as usual.
• Prophylactic Antibiotics: Infection/ surgery

35. HEPATITIS
• Consult with physician- patient status and planned dental
treatment.
• If surgery necessary-obtain preoperative prothrombin
time, bleeding time, discuss abnormal results with
physician.
• Adhere to universal precautions.
• Use isolated operatory.

36. • Use rubber dam to minimize contact with saliva and blood.
• Minimize aerosol production by using slow speed handpiece , use air
syringe judiciously.

37. NORMAL VALUES
Bleeding time 3-5 min
Clotting time 6-8 mins
Prothrombin time 11-14 sec

38. BLOOD DISEASES
• Consultation with patients hematologist.
• Avoid aspirin and aspirin containing compounds and NSAID’S
• Use acetaminophen.
• RCT can be carried out with precautions and special care to avoid
instrumentation beyond the apex.
• Careful application of rubber dam and matrix band to avoid bleeding.

39. RESPIRATORY DISEASES
Asthma
1. Identification of patient by history.
2. Avoidance of known precipitating factors.
3. Medical consultation for severe and active asthma.

40. ASTHMA
• Have patient bring medication inhaler to every appointment and keep it
available.
• Avoid aspirin medications and use acetaminophen. Avoid barbiturates.
• Avoid rubber dam application.
• Avoid erythromycin and ciprofloxacin patients taking theophylline.
• LA considerations-elect to avoid solutions containing epinephrine
because of sulfite preservative.
• Provision of stress free environment.

41. OTHER SERIOUS DISEASES
Human Immunodeficiency Virus (HIV) and Acquired
Immunodeficiency Syndrome(AIDS)
• Although saliva is not the main route for transmission of HIV, the virus
has been found in saliva and its transmission through saliva has been
reported.
• Infected blood can transmit HIV, and during some surgical procedures it
may become mixed with saliva.

42. • Latex gloves and eye protection are essential for clinician and staff.
• Vital aspect for HIV patient is to determine the current CD4+
lymphocyte count and level of immunosuppression.

43. HIV/AIDS
• Patients having a CD4+ cell count exceeding 350 cells/mm3 may
receive all dental treatments.
• If the count is less than 200cells/mm3 or severe neutropenia will
have increased susceptibility to opportunistic infections and may be
effectively medicated with prophylactic drugs.
• Consult patient’s physician for formulating any treatment plans.

44. PREGNANCY
• Pregnancy is not a contraindication to endodontics but it does modify the
treatment plan.
• Local anesthetics administered with epinephrine is generally considered
safe.
• Second trimester- safest. L.A :- Lidocaine, etidocaine , and
prilocaine.
Many antibiotics including
penicillins, clindamycin, and
azithromycin.
Acetaminophen
Acyclovir
Prednisone
Antifungals including fluconazole
and nystatin.

45. Name of drug Brand or generic name Use
Acetaminophen Tylenol Used for pain fever and
headche
Acyclovir Zovirax and valtrex Antiviral for herpes
infection
Antacids (aluminum,
magnesium)
Maalox or Mylanta Stomach upset
(dyspepsia)
Aspirin Aspirin is best avoided
during breastfeeding;
however, some expert
opinion indicates that
low-dose (75 to 162 mg
daily) aspirin may be
considered as an a
thinning drug for use in
breastfeeding women;
avoid high-dose aspirin
Used for pain relief
Bupivacaine Marcaine Local anethetic
List of
drugs safe
for
lactating
mothers

46. Name of the drug Brand or generic name Use
Cephalosporins(i.e. Keflex or
cephalexin)
Most cephalosporins are
considered compatible with
breastfeeding; may interfere with
gut flora in infant leading to
diarrhea or thrush
Broad-spectrum antibiotics for
infections
Clotimoxazole Lotrimin, clotrimazole troches or
topical; poor oral bioavailability,
unlikely to adversely affect the
breastfed infant
Used to treat yeast and fungal
infections
Contraceptives (progestin-only
norethindrone)
Micronor, Errin, Heather, other
norethindrone brands; estrogen
may lower milk production and
protein content.
Rx; Used for birth control;
generic, lower cost versions of
norethindrone are available
Corticosteroids Prednisone or prednisolone Used to treat inflammation of
joints and other conditions

47. Drug name Brand or generic name Use
Erythromycin erythrocin Used for skin and respiratory
infections
Ibuprofen Motrin ,advil Pain relief
Lidocaine Xylocaine Local anesthetic
Penicillin Amoxiciilin Infection

48. CLINICAL EXAMINATION
• It should follow a logical sequence i.e. from general to specific i.e.
from the more obvious to the less obvious, from the external to the
internal.

49. VITAL SIGNS:-
• First step is to check all the vital signs.
• Blood pressure, pulse, respiratory rate, temperature.
• Breathlessness, color change, altered gait, or unusual body movements
should be observed.

50. EXTRA-ORAL EXAMINATION
• Patients must be examined for –
• asymmetries, localized swelling, changes in color or bruises, abrasions, cuts or scars
and similar signs of disease, trauma or previous treatment.
• Face, lips and neck - which may be palpated if the patient reports soreness or if there
are apparent areas of inflammation.
• Painful or enlarged lymph nodes.
• The extent and manner of jaw opening.
• The TMJ examination.

51. INTRA-ORAL EXAMINATION
• It begins with general evaluation of oral structures.
• Examination of oral vestibules and buccal mucosa.
• Lingual and palatal soft tissues are also evaluated.
• The presence of tori should be noted.

52. • Finally, the general inspection starts which includes the following:-
1. Carious lesions
2. Enamel or dentin fractures
3. Discolorations
4. Any developmental anomalies
5. Missing teeth
6. Presence of supernumerary or retained deciduous teeth .

53. 1. Visual and tactile
inspection
2. Percussion
3. Palpation
4. Mobility and
Depressibility
5.Bite test
6.Thermal tests(hot and cold)
7.Electric pulp test
8. Anesthetic cavity
9. Test cavity
• The objective symptoms are also determined by various tests and
observations performed by the clinician. These test are as follows:-

54. VISUAL AND TACTILE INSPECTION
• Check for three C’s :- color, contour and consistency for both soft and hard
tissues.
• It is usually done with one’s eyes, fingers, an explorer, and a periodontal
probe.
• The patient’s teeth should be examined in good light under dry conditions.
• Visual examination should include soft tissue adjacent to the involved tooth,
for detection of swelling.

55. • The periodontal probe should be routinely used to determine the status of
the suspected tooth and adjacent teeth.
• Periodontal pocket depth must be measured and recorded.
• Poor periodontal prognosis may be contraindication to root canal
therapy.

56. GLICKMAN’S CLASSIFICATION OF FURCATION
DEFECT
Grade 1 • Incipient lesion when the pocket is suprabony
involving soft tissue and there is slight bone loss.
Grade 2
• Bone is destroyed on one or more aspects of the
furcation but probe can only penetrate partially
into the furcation.
Grade 3 • Intra-radicular bone is completely absent but the
tissue covers the furcation.
Grade 4 • Through and through furcation defect.

57. PERCUSSION
• This test is done to evaluate the status of the periodontium around the
tooth.
• Procedure.
• A sensitive response generally indicates acute apical periodontitis.

58. • This test can also be misleading.
• Percussion is used in conjunction with other periodontal tests, namely,
palpation, mobility, and depressibility.

59. PALPATION
• This simple test is done with the fingertip, using the light pressure to
examine tissue consistency and pain response.

60. • This test is useful in locating the swelling over an involved tooth and
determine the following:-
a) Whether the tissue is fluctuant and enlarged sufficiently for incision
and drainage.
b) Presence, intensity and location of pain.
c) Presence of location of adenopathy.
d) Presence of bone crepitus.

61. • Diagnostically,
posterior teeth- submaxillary lymph nodes are involved.
lower anterior teeth- submental lymph nodes are involved.
• When the infection is confined to the pulp , palpation is not diagnostic.
• Percussion, palpation, mobility and depressibility are tests of
periodontium rather than that of pulp.

62. MOBILITY – DEPRESSIBILITY TESTING
• The mobility test is used to evaluate the integrity of the attachment
apparatus surrounding the tooth.
• This test is done by moving the tooth laterally in its socket by using the
fingers or, preferably, the handles of two instruments.

63. Mobility test

64. • The main objective – to determine whether the tooth is firmly or
loosely attached to its alveolus.
• The amount of movement  of the condition of the periodontium;
the greater the movement , the poorer the periodontal status.
• The test for depressibility  Moving a tooth vertically in its socket.

65. • This test is also done with the help of an instrument or with fingers.
• When depressibility exists, the chance for retaining the tooth ranges
from poor to hopeless.

66. CLASSIFICATION OF TOOTH MOBILITYFirstdegree
Noticeable
movement of
the tooth in its
socket
Seconddegree
Movement of
the tooth within
the range of
1mm.
Thirddegree
Movement
greater than 1
mm or when
the tooth can be
depressed.

67. PULP TESTS
• Application of cold and heat to a tooth to determine sensitivity to
thermal changes.
• Although both are tests of sensitivity , they are dissimilar and are
conducted for different diagnostic reasons.
• A response to cold indicates a vital pulp.
• A heat test is not a test of pulp vitality i.e. it indicates necrosis.

68. Other diagnostic differences :-
Cold tests Heat tests
Response- vital pulp, regardless of
whether that pulp is normal or
abnormal.
An abnormal response to heat
usually indicates presence of pulpal
or periapical disease.
Positive response- patient quickly
points to the tooth structure
The heat response caN be localized
or diffuse and at times , referred to
a different site.
Quick reaction Delayed reaction.

69. HEAT TESTING
• The area to be tested is isolated and dried, warm air is directed to the exposed surface
of the tooth and the patient’s response is noted.
• If a higher temperature is needed to elicit a response , one should use hot water , a
hot burnisher , hot gutta percha or hot compound, or any instrument that can deliver
a controlled temperature to the tooth.

70. • When using a solid substance, such as hot gutta percha , the heat is applied to the
occluso-buccal third of the exposed crown.
• When a response occurs, the heat should be removed immediately.
• Care should be taken to avoid using excessive heat or prolonged application of heat
to the tooth.

71. • Another technique for heat test using application of hot water.
• The tooth to be tested is isolated under a rubber dam .
• The tooth is then immersed in coffee hot water delivered from a syringe
and the patient reaction is noted.

72. COLD TESTING
• Cold can be applied in several different ways.
• A stream of cold air can be directed against the crown of the previously dried tooth
and also at the gingival margin.
• If no reaction occurs, the tooth can be isolated under a rubber dam and sprayed with
ethyl chloride, which evaporates so rapidly that it absorbs heat and thereby cools the
tooth.
• Another method is to apply a cotton pellet saturated with ethyl chloride to the tooth
being tested.

73. Endo ice refrigerant spray Endo cool spray

74. • Another simple method is application of cold to a tooth is by wrapping a sliver of ice
in wet gauze, and placed against the facial surface of the tooth.
• Carbon dioxIde snow or dry ice has also been used for application of cold to teeth.
• The use of dry ice has been described by Ehrmann.
• The use of dry ice has been found effective in evaluating the pulpal response in teeth
with full coverage crowns where EPT is not possible.

75. • Another reliable method is use of refrigerant spray like 1,1,1,2- tetrafluroethane(-
26.2degC)
• The sprayed cotton pellet is applied to the mid-facial area of the tooth or the crown.
• Adjacent or contralateral teeth should also be tested to establish a baseline response.

76. • Frozen carbon dioxide and refrigerant spray – superior to other cold testing methods
and equivalent or superior to EPT.
• One study found-periodontal attachment loss and gingival recession may influence
the reported pain response with cold stimuli.
• To be most reliable, cold testing should be used in conjunction with an electric pulp
tester.
• If a mature, non traumatized tooth does not respond to both cold testing and EPT ,
then the pulp should be considered necrotic.

77. PULPAL DIAGNOSISBASEDON PATIENT RESPONSES TO THERMAL
TESTS
Pulpal diagnosis Response to cold or heat
Normal Patient reports a thermal sensation and stops
feeling it when the stimulus is being removed.
Reversible pulpitis Thermal sensation causes discomfort/pain and the
magnitude of response is different from adjacent
and/or contralateral teeth;sensation may linger
briefly.
Symptomatic irreversible pulpitis After thermal stimulus is applied, patient reports
pain/discomfort is more pronounced than on
adjacent teeth and/or contralateral tooth ; sensation
lingers.
Asymptomatic irreversible pulpitis Same response as normal or reversible pulpitis,
except the patient has a history of pulpal
inflammation such as caries, carious exposure, or
trauma.
Necrosis Patient reports feeling no sensation when thermal
stimulus is applied for more than 10 seconds.

78. ELECTRIC PULP TEST
• The tooth to be evaluated is dried and isolated.
• A control tooth of similar tooth type and location in the arch should be tested first in
order to establish a baseline response.
• The suspected tooth should be tested twice to confirm the results.
• The tip of the testing probe is placed in contact with the tooth structure and it must
be coated with water or petroleum based medium.

79. • The most commonly used medium is toothpaste.
• The coated probe tip is placed in the incisal third of the facial or buccal area of the
tooth to be tested.

80. • Once the probe is in contact with the tooth , the patient is asked to touch or grasp the
tester probe, unless a lip clip is used.
• This completes the circuit and initiates the delivery of electric current to the tooth.
• The patient is asked to remove his or her finger from the probe when a tingling or
warming sensation is felt in the tooth.
• The readings from EPT are recorded.

81. PICTURE SHOWING ELECTRIC PULP TEST

82. Potential
common
interpretati
on errors of
responses
obtained
from EPT
False positive responses
Partial pulp necrosis
Patients high anxiety
Ineffective tooth isolation
Contact with metal restorations
False negative responses
Calcific obliterations in the root canal
Recently traumatized teeth
Immature apex
Drugs that increase patient’s threshold for pain
Poor contact of pulp tester to tooth

83. • One study compared the ability of thermal and electric pulp test results and found the
sensitivity of the test
• For cold test-0.83
• For heat test-0.86
• For EPT- 0.72
• Specificity for the test :-
• Cold test and EPT-0.93
• Heat test – 41%

84. • From the results of the testing, it was found that the cold test had an accuracy of
86%, the electric pulp test has an accuracy of 81% and the heat test 71%.
• Cold tests are shown to be more reliable in younger patients with less developed root
apices.
Reliability of the tests

85. DISEASES OF PULP
• Inflammatory diseases of dental pulp:-
(a) Reversible pulpitis
-Symptomatic (acute)
-asymptomatic (chronic)
(b)Irreversible pulpitis
-Symptomatic(acute)
abnormally responsive to cold
abnormally responsive to hot

86. -Asymptomatic (chronic)
asymptomatic with pulp exposure
hyperplastic pulpitis
internal resorption
• Pulp degeneration
(a) Calcific
(b) Others
• Pulp necrosis Grossman’s 11th edi.

87. INTERPRETATION –DIAGNOSIS
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

88. REVERSIBLE PULPITIS
• Clinical diagnosis based on subjective and objective findings, indicating that the
inflammation should resolve and the pulp return to normal.
• Increased response to Thermal stimuli (cold)- sharp pain.
• Subsides as soon as the stimulus is removed/ in few seconds.
• Patients who complain of symptoms related to sweets also are typically exhibiting a
reversible pulpitis.
• Stopping the irritation will allow the pulp to return to normal.

89. IRREVERSIBLE PULPITIS
• Clinical diagnosis based on subjective and objective findings.
• Thermal changes (cold): sharp pain , dull prolonged ache- last upto an hour or
so.
• Defined as the point where an inflamed pulp is no longer capable of healing
and returning to normal.
• Painful thermal responses, particularly to cold.
• EPT: not of value

90. PULP NECROSIS
• Death of dental pulp.
• Non responsive to pulp testing.
• Tooth becomes asymptomatic until such time when there is an extension of the
disease process into the peri radicular tissues.
• No response to cold and electric pulp tests.
• Response to heat , if applied for an extended period of time.
• May be partial or complete.
• Tooth may present with confusing symptoms.

91. RECENT TRENDS IN PULP VITALITY ASSESSMENT

92. LASER DOPPLER FLOW-METRY
• It’s a method used to assess pulpal blood flow.
• A diode is used to project an infrared light beam through the crown and pulp chamber of a
tooth.
• The infrared light beam is scattered as it passes through the pulp tissue.
• Doppler principle- light beam’s frequency will shift when hitting moving red blood cells but
will remain un-shifted as it passes through static tissue.

93. Principle of laser Doppler flow metry

94. LASER DOPPLER FLOWMETRY
• The average Doppler frequency shift will measure the velocity at which the red blood cells
are moving.
• Was first introduced in the early 1970’s.
• The first study showing that LDF could differentiate between vital and non vital pulps in
humans was published in 1986 by Gazelius et al.

95. • Studies have found LDF to be a reliable and accurate method of assessing pulpal blood flow.
• Advantage – collection data is based on objective findings rather than subjective responses.
• Luxation injuries are known to cause inaccuracies in EPT and thermal pulp testing but LDF
has shown to be a great indicator of pulp vitality in these cases.
• Not routinely used in dental practice.

96. PULSE OXIMETRY
• It is a non invasive device.
• Widely used in medicine, it is designed to measure the oxygen concentration in the blood
and the pulse rate.
• It works by transmitting two wavelengths of light, red and infrared, through a translucent
portion of a patient’s body(e.g. a finger, earlobe or tooth)

98. • Some of the light is absorbed as it passes through the tissue.
• The amount absorbed depends on the ratio of oxygenated to deoxygenated hb in the blood.
• On the opposite side of the targeted tissue, a sensor detects the absorbed light.

99. • On the basis of the difference between the light emitted and the light received, a micro
pressor calculates the pulse rate and oxygen concentration in the blood.
• The transmission of light to the sensor requires that there be no obstruction from
restorations.

100. Special tests

101. BITE TEST
• This test is usually used to identify a cracked tooth or fractured cusp.
• This test is also helpful in diagnosing cases wherein the pulpal pathosis has extended
into the peri radicular region causing apical periodontitis.

102. • The tooth slooth and the Frac finder are the popular commercially available devices
for the bite test.
• The clinician should note whether the discomfort or pain occurs during the act of
biting or during the release of bite force.
• Pain on biting- apical periodontitis.
• Pain on release of biting force- cracked tooth.

103. STAINING AND TRANSILLUMINATION
• To determine the presence of a crack in the surface of a tooth, the application of a stain to
the area is often of great assistance.
• Methylene blue dye when painted on the tooth surface with a cotton tip applicator , will
penetrate into cracked areas.
• The excess dye may be removed with a moist application of 70% isopropyl alcohol.

105. • The dye will indicate possible location of the crack.
• Another method is by transillumination using a bright fiber optic light probe on the surface
of the tooth.
• Directing a high intensity light directly on the exterior surface of the tooth at the CEJ may
reveal the extent of the fracture.

106. • Teeth with fractures block trans illuminated light.
• The part of the tooth that is proximal to the light source will absorb this light and glow,
whereas the area beyond this fracture will not have light transmitted to it and will show as
gray by comparison.
• Although the presence of a fracture may be evident using dyes and trans illumination, the
depth of the fracture cannot always be determined.

107. Trans illumination test showing fracture line

108. TEST CAVITY
• The test cavity method for assessing pulp vitality is not routinely used since, by
definition , it is an invasive irreversible test.
• This method is used only when the results of all other tests are inconclusive.
• For example, tooth suspected of having a pulpal disease has a full coverage crown.

109. • A small round bur is used to prepare a class 1 cavity and patient is not anaesthetized .
• The patient is asked to respond if any painful sensation is felt during the drilling
procedure.

110. ANESTHETIC TESTING
• Test restricted to patients who are in pain at the time of the test, when the other tests
have failed to identify the tooth.
• Objective:- to anesthetize a single tooth at a time until the pain disappears and is
localized to a single specific tooth.

111. • Technique :-Infiltration or Intra ligament injection is given to the most posterior
tooth in the area suspected of being the cause of pain.
• If the pain persists after anesthesia- anesthetize the next tooth mesial to it and
continue till the pain disappears.

112. RADIOGRAPHIC EXAMINATION AND
INTERPRETATION
Introduction
Radiographs are the “eyes” of the dentist when performing many procedures.
Essential for diagnosis and treatment planning, determining anatomy, managing treatments
and assessing outcome.
This was first introduced by Wilhem Konrad Roentgen in 1895.
Their application to dentistry were seized upon 14 days after Roentgen’s announcement by
Dr.Otto Walkoff.
Dr. C. Edmund Kells :- first clinic in the united states gave the use of x-ray to determine
tooth length during root canal therapy.

113. APPLICATION OF RADIOGRAPHY TO
ENDODONTICS
• Aids in diagnosis of hard tissue alterations of the teeth and peri radicular structures.
• Determine the number, location, shape, size and direction of roots and root canals.
• Estimate and confirm the length of canals.
• Localize ,hard to find , or disclose unsuspected, pulp canals by examining the position of an
instrument within the root.

114. • Aids in locating a pulp space markedly calcified and/or receded.
• Determine the relative position of structures in facial-lingual dimension.
• Confirm the position and adaptation of master cones.
• Aid in the evaluation of obturation.

115. • Facilitate the examination of soft tissues for tooth fragments and other foreign bodies
following trauma.
• Aid in localizing a hard to find apex during root end surgery.
• Helps to confirm, following root end surgery and before suturing, that all tooth fragments
and excess filling material have been removed from the apical region and the surgical flap.
• Evaluate in follow up films, the outcome of the treatment.

116. LIMITATIONS OF RADIOGRAPHS
• Two-dimensional shadows on a single film.
• They are suggestive of only and are not the singular final evidence in judging a
clinical problem.
• The greatest fault with radiograph relates to its physical state. As with any shadow,
these dimensions are easily distorted through improper technique , anatomic
limitations or processing errors.

117. • The buccal lingual dimension is absent on a single film and is frequently overlooked.
• Radiographs are infallible. Various states of pulpal pathosis are indistinguishable in
the x-ray shadow.
• Neither healthy nor necrotic pulps can cast an unusual shadow.

118. TECHNOLOGY SYSTEMS
Radiographic approaches
Traditional method Digital system

119. RADIOGRAPHIC INTERPRETATION
• Proximal surfaces
• Typical radiographic appearance:-

120. • Occlusal surfaces:-

121. • Buccal and lingual surfaces:-

122. • Root surfaces:-

123. • Secondary caries:-

124. • Radicular cyst

125. PROGNOSIS
• Prognosis is the term used to describe the prediction of the probable course and outcome of a
disease or condition as well as the outcome expected from an intervention, be it preventive
or operative.
• Prognosis can be excellent, good , fair , poor and even hopeless.
• Depends on risk factors.
• Depends on the skill of the dentist.
• Depends on the disease indicators.

126. TREATMENT PLANNING
The development of dental treatment plan consists of four steps:
• Examination, problem identification and risk assessment.
• Decision to recommend intervention.
• Identification of treatment alternatives.
• Selection of treatment with the patient’s involvement.

127. PHASES
• Urgent phase/Emergency phase
• Control phase
• Re evaluation phase
• Definitive phase
• Re care or Re Assessment phase

128. URGENT PHASE
• Begins with the thorough review of the patient’s medical condition and
history.
• A patient presenting with swelling, pain, bleeding or infection should
have these problems managed as soon as possible , before initiation of
subsequent phases.

129. CONTROL PHASE
• Goal of the phase:- to remove etiologic factors and stabilize the patient’s
dental health.

130. These goals are accomplished by :-
1. Eliminating active disease such as caries and inflammation.
2. Removing conditions preventing maintenance.
3. Eliminating potential causes of disease.
4. Beginning preventive activities.

131. • Example of control phase includes:- extractions, endodontics,
periodontal debridement and scaling; occlusal adjustment; caries
removal; replacement or repair of defective restorations such as those
with gingival overhangs; and use of caries control measures.

132. RE EVALUATION PHASE
• This phase allows time between the control and definitive phases for
resolution of inflammation and healing.
• Home care habits are reinforced, motivation for further treatment is
assessed, and initial treatment and pulpal responses are re evaluated
before definitve care is begun.

133. DEFINITIVE PHASE
• After the dentist reassesses initial treatment and determines the need for
further care, the patient enters the corrective or definitve phase or
treatment .
• This phase may include endodontic, periodontal, orthodontic and
surgical procedures before fixed or removable prosthodontic treatment.

134. RE-CARE AND REASSESSMENT PHASE
• The re assessment phase includes regular re-evaluation examinations
that
-- may reveal the need for adjustments to prevent future breakdown and
-- provide an opportunity to reinforce home care.

135. CONCLUSION
• Proper diagnosis and treatment planning play a crucial role in the quality of dental care.
Each patient must be evaluated individually in a thorough and systematic manner.
• Patients must be explained about the disease and the treatment options and they must have
active role in the whole process.
• Patients must be advised about the different risk factors and benefits of the proposed
treatment.
• This whole process can be challenging but also can be rewarding if done thoroughly and
properly with the patient’s best interest in mind.

136. REFERENCES
• Cohen ‘s pathways of the pulp 11th edition.
• Grossman Endodontic Practice 11th edition.
• Ingle’s endodontics 6th edition.
• PROTOCOLS FOR HYPERTENSIVE PATIENT MANAGEMENT IN THE DENTAL
OFFICE RAMASAMY CHIDAMBARAM Lecturer – Faculty of Dentistry, AIMST
University, Semeling, 08100 Bedong, Kedah Darul Aman, Malaysia.
• K.D.Tripathi Book of Pharmacology 9th edition.
• Sturdevant’s Book of Operative Dentistry – South Asian Edition
• Ghom’s Book of oral medicine -2ND EDITION
• Soben Peter – essentials of preventive and community dentistry – 4th edition.

137. Thank you