ENDODONTIC

DIAGNOSIS

D R . S U C H E TA P R A B H U
THIRD YEAR MDS
28/06/18
QUESTIONS ASKED
PREVIOUSLY(20 MARKS)
• Discuss in detail various pulp pathologies
and management in primary dentition
• Pain experienced due to pulpalgia in a
child
• Pathways of pulp in deciduous teeth and
how it affects endodontic treatment
• Discuss the scope and limitations of
pediatric endodontics
QUESTIONS ASKED
PREVIOUSLY
• 100 markers
• Dental Pulp in health and disease
• Diagnostic aids used in pediatric dentistry
• Recent concepts and controversies in pediatric endodontics
• Recent advances in pediatric endodontics
• 7 markers
• Recent concepts in pulp vitality testing
• Limitations of pulp vitality tests in children
• Internal root resorbtion
• Calcium hydroxide based internal resorbtion
CONTENTS

• Introduction to pulpal diseases

• Reversible pulpitis
• Irreversible pulpitis
• Pulpal necrosis
• Diagnosis
• Diagnostic method
• Medical history
• Drugs & medication history
• Dental history
• Subjective symptoms
• Clinical observations
• Clinical tests
DENTAL PULP

• The Pulp is a soft mesenchymal connective tissue that occupies

pulp cavity in the central part of the teeth.
‘‘The pulp lives for the dentin and the
dentin lives by the
grace of the pulp. Few marriages in nature
are marked
by a greater affinity.’’ Alfred L. Ogilvie

Average intrapulpal
pressure =10mm Hg
13 mm in reversible
35+ mm Hg
irreversible
HISTOLOGIC ZONES
AFFERENT PAIN PATHWAY
Impulse from A
Pons Thalamus
delta or C fibres
• Afferent pain path

Division of Cortex interprets as

Plexus of Raschkow
trigeminal nerve pain

Nerve trunk in
Apical foramen exit
central zone of pulp
PERIPHERAL NERVE FIBERS
DISEASES OF THE PULP
Causes of According to
pulpitis duration
Mechanical Acute
Chemical Chronic
Thermal
Bacterial

Classification
(severity) According to Classification
Reversible communication (Involvement)
Irreversible with external Focal/Subtotal/Part
Pulp environment ial
degeneration Pulpitis Aperts Total/Generalised
Pulpal Pulpitis clausa
necrosis
 REVERSIBLE PULPITIS Caused by noxious
stimuli
• Mild to moderate
inflammatory condition
• Trauma
of pulp
• Disturbed occlusal
• Pulp is capable of
relationship
returning to un-
• Thermal shock
inflammed state
• Dental caries
following removal of
stimuli

Management
Clinical Features
periodic care
Sharp pain lasting for a
early insertion of
moment
filling if a cavity has
Often brought on by hot food
developed
or beverages, cold air
removal of noxious
Tooth responds to electric
stimuli
pulp testing at lower
current
 IRREVERSIBLE PULPITIS
Causes
persistent inflammatory  bacterial
condition of pulp involvement of
may be symptomatic or pulp through caries
asymptomatic  chemical
caused by noxious  thermal
stimulus  mechanical injury

Types
Symptomatic
Assymptomatic
(chronic hyperplastic
pulpitis)
(internal resorbtion)
IRREVERSIBLE PULPITIS
Early Stage pain Late stage pain

• sharp
More severe or throbbing as if tooth is under
• piercing constant pressure

• shooting

• generally severe

Patient is often awake at night due to pain

• bending over or lying down exacerbates

pain which is
Increased by heat & sometimes relieved by
due to change in
cold
intrapulpal pressure
Continued cold applied may exacerbate pain
Reversible Irreversible Pain
occurs without
Pain is
a stimulus
generally
traceable to a More severe
stimulus
Lasts longer
 PULP POLYP(PULPITIS
APERTA)
an excessive exuberant proliferation
of chronically inflamed dental pulp
tissue
asymptomatic
seen only in teeth of children & young
adults

polypoid tissue appears

• fleshy reddish pulpal mass
Filling most of pulp chamber
or cavity even extends beyond
confines of tooth
• tissue easily bleeds
because of rich network
of blood vessels
INTERNAL RESORPTION
• Idiopathic slow or fast progressive resorptive process occuring
in
dentin of the pulp chamber or pulp canal of the tooth.
• Exhibit no additional symptoms other than existing pulpitis.
• Crown may appear as pink ,when resorption is in coronal
portion.(Pink tooth)
• Resorption involving the root canal appears as round to oval R/L
area that extends from pulp canal.
PULPAL NECROSIS
death of pulp
may be partial or total
depending on whether part
or the entire pulp is
involved

Causes
sequelae of inflammation
following trauma
• pulp is destroyed before
an inflammatory reaction
TYPES OF NECROSIS

• soluble portion of •results when proteolytic

Liquefaction Necrosis
Coagulation Necrosis

tissue is precipitated enzymes convert the tissue into

softened mass
or converted into a solid
material •liquid or amorphous debris

• tissue is converted into tissue

mass consisting chiefly of
coagulated
•proteins
•fats
•water
 Diagnosis:
‘The art and science of
detecting
deviations from health
and the cause and
nature thereof’
DIAGNOSTIC METHOD

Dental history/ Evaluation of pain

Medical history signs/ symptoms

DIAGNOSTIC APPROACHES
METHODS Bite test
Pulp testing Test cavity
Palpation Staining/ Transillumination
Percussion Selective anesthesia
Radiography
CASE HISTORY
CHIEF COMPLAINT
HISTORY OF PRESENT
ILLNESS • Duration
• Mode of onset
• Progression
• Severity
• Nature
• Aggravating/relieving factors
• Postural variation
• Any medications/treatment received for the same

Elaboration of
complaint(pain)
PAIN
• Most common complaint that leads to dental
treatment
• According to intensity

Severe pain

• Cannot
Moderate
Mild pain controlled
pain
• Controlled with
• Controlled
by simple analgesics
with narcotic
analgesics • Require
analgesics
elimination

of cause
 According to nature Localization of pain

• Localised when patient can

• Pricking/piercing point to a specific tooth or site

• Throbbing • Sharp , piercing and

lancinating pain in a tooth
• Lancinating
responds to cold and is easy to
• Aching
localize
• Dull, boring, gnawing
• Dull, boring pain is diffuse and
responds abnormally to heat
than to cold is difficult to
localize.
ACCORDING TO DURATION
• Pain of short duration & separated by
Intermittent wholly pain free period

Continuous • Pain of longer duration

Recurrent • Two or more similar episodes of pain

• Characterized by regularly
Periodic recurring episode
ACCORDING TO ONSET

• Pain occurs • Provocation causes • When evoked

without being painful sensation response is out of
provoked proportion to the
stimulus

Spontaneous Induced Triggered

SWELLING

 Anatomical location (site)

 Duration
 Mode of onset
 Symptoms
 Progress of swelling
 Associated features
 Secondary changes
 Impairment of function
 Recurrence of swelling
PAST MEDICAL HISTORY
-Anemia
-Bleeding disorders
-Cardio respiratory disorders
-Drug treatment and allergies
-Endocrine disorders
-Fits and faints
-Gastrointestinal disorders
-Hospital admissions and surgeries
-Infections
-Jaundice and liver diseases
-Kidney disease

Checklist by Scully & Cawson

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

EXTRAORAL EXAMINATION

• Facial symmetry
• Lymph node examination
INTRAORAL EXAMINATION
Soft tissue examination:
Swelling/ fistula

Crown discoloration: non vital pulp

Deep carious lesions/ fractures: visual
examination & probing
PERCUSSION
Inflammatory condition of the apical periodontium
Symptomatic apical periodontitis: more sensitive
Periodontal/ endodontic etiology,occlusal
trauma,combination with marginal periodontitis
PALPATION
Vestibular region: apical region of the root tips
Tenderness, swelling, fluctuation,hardness, crepitation
Tip of index finger
Usefulness increase with skill & clinical experience
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
 PERIODONTAL PROBING
Endodontic & periodontic lesions mimic each other concurrently
Entire circumference probed
Narrow isolated probing defects:
 Periodontal disease
 Sinus- like track following periapical
pathosis
 Vertical groove defect
 Cracked teeth
 Vertical root fractures
 External root resorption
TESTS FOR CRACKED TOOTH
Transillumination
 Fiberoptic light
 Coronal cracks/ vertical root
fractures
 Minimal background lighting
 Light placed on varied surfaces of
coronal tooth structure/
root after flap refection
 Light traverses fracture lines visually
detected
 Fractured Segment near the
 light appears brighter
DYE STAINING

3 methods:
• Remove restoration: Directly revealing fracture line
• Dye incorporated into ZOE mixture & placed
• Patient chews on disclosing tablet
BITE TEST

• Wooden stick- opposing teeth

• Tooth sloth, frac finder
• Patient bites down & pain elicited upon release
• Rubber dam sheet- cracked cusp flexes

Interpretation
Pain on biting: Symptomatic apical
periodontitis
Pain on release of force: Cracked tooth
PULP TESTS
Ideal technique: non invasive, painless, standardized,
reproducible, reliable,inexpensive, easily completed & objective
*Chambers. 1982

Pulp sensibility Pulp vitality tests

• Thermal tests • Laser doppler

• Electric pup tests flowmetry

• Test cavity • Pulse oximetry

• Tooth temperature
Measurement
VALUE OF DIAGNOSTIC
TESTS
Specificity: The ability
of a test to detect
the absence of a result

Positive predictive value: Heat: relatively high

The probability sensibility; but least
that a positive test result accurate being the least
actually specific
represents a disease Cold test: more
positive tooth accurate than EPT

Negative predictive value:

The probability
that a tooth with a negative
test result is
actually free from the disease
THERMAL TESTS RATIONALE
First reported by Jack in 1899
Often inappropriately referred to as ‘Vitality
tests’
More reliable than EPT
Inexpensive & easy-to- use equipment
Patient’s pain reproduced

• C fibres (slower)

Heat test • Dull long lasting pain

• A fibres faster

Cold test • Hydrodynamic movement of fluid in

dentinal tubules
• Sharp localized pain
RESPONSE
Clinically norma;l pulp
Reversible pulpitis
Mild to moderate transient response to
Thermal stimuli (cold)- sharp pain
cold & electrical stimuli
Subsides as soon as the stimulus is
Response subsides in few seconds on
removed/ in few seconds
removal of stimulus

Do not usually respond to heat tests

Irreversible pulpitis

Thermal changes (cold): sharp pain , dull Pulp necrosis

prolonged ache- last upto an hour or so No response with EPTs & thermal tests

Valuable: stimulus as reported by patient No indication of infection expected from

applied & pain reproduced & assessed these

EPT: not of value

RESPONSE
Pulp Necrobiosis
Difficult to diagnose
History : pulpitis
Pulp tests: necrosis
Vague response to
EPTs, cold tests
Acute apical periodontitis
Maybe associated with
pulpitis
Pulp status assessed
before treatment
Acute apical abscess-
Negative
Lateral periodontal abscess-
Positive
HEAT TEST
Heat: fluid expansion- A fibers
Inflamed pulp: C-fibers; lasting response
Low diagnostic accuracy- not used as single method
Electrical heat sources
Touch ‘N Heat/ System B- 150oC
Inserts: Hot Pup Test Tip
Continuous heat mode- intensity set
Tooth surface lubricated

Frictional heat
 Rubber cup- prophylaxis
 Buccal surface
 Best, easiest & safest
 Gold crown
 Seldom used today
COLD TESTS
Materials used
DDM(dichlorodifluoromethane)
Endo ice (1,1,1,2
tetrafluroethane)
CO2 snow
Pencil of ice
Ice cold water
Ethyl chloride
 MECHANISM OF COLD TEST
Cold application for more than 15 seconds

+ve Short sharp pain Excruciatingly

response that disappears painful
Similar to rapidly on response that No
contralatera removal of lingers even response
l stimulus on stimulus
removal

Healthy Non vital

Reversible Irreversible
pulp tooth
pulpitis pulpitis
ELECTRIC PULP TEST

Magitot 1963 Seltzer

1986
possible use in
1867
inflammatory Dummer et al EPT
Use of electricity pulps +readout

1876 1976 Grossmann

Marshall &
Woodward on
vital & nonvital
pulps
ELECTRIC PULP TEST
• Electric Pulp Test - Rationale

• Current overcomes resistance of enamel & dentin

• Simulate A fibres
• Brief sharp sensation/tingling

• Ionic shift in tubules

• Local depolarization in action potential

• No blood flow- pulp becomes anoxic & A fibers cease to function

Jacobson on location of probe tip

for consistent results.
ELECTRICAL PULP TESTING
Benchtop style digital EPT

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 Handheld digital style EPT
nerve stimulation
Handheld style analog EPT
TECHNIQUE OF USE
Isolate area & air dry all teeth.

Check tester for function

Apply an electrolyte to electrode, place it against

tooth

Retract patients lip away from electrode. Place lip

clip

Adjust rheostat to minimum current slowly

increasing it. Check for response
FALSE RESPONSE
Failure to
complete the
circuit
Equipment
Patient related factors problems
Tooth characteristics Probe
placement
Restored teeth Interface
Supporting tissues media

Apex maturation
Repeated trials
Psychological state
Physiological state
FALSE POSITIVE & NEGATIVE

Necrotic pulp responds to testing. Vital pulp that does not respond to
Stimulation of adjacent teeth stimulation
Inadequate contact with the stimulus
The response of vital tissue in multirooted tooth with
pulp necrosis in one or more canals Tooth calcification

Patient interpretation: subjectivity Immature apical development

Traumatic injury

Subjective nature of the tests

Elderly patients – regressive neural changes

Analgesics for pain

Traumatic injury
LIMITATIONS OF EPT

No information on health status/ integrity

Unreliable for immature teeth
Not suitable with full coverage restorations
Chances of ventricular fibrillation
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
5. Difficult to administer & inconclusive in children
6. Weaker response- aged pulp
7. Extensive restorations, pulp recession, pulp calcification
8. Lack of reproducibility
SAFETY CONCERNS

Zach et al. Increase in 11 degree C without cooling can damage pulp. Hence contact to be minimized
less than 5 secs.

Lutz et al carbon dioxide snow causes cracks. Later disproved by Peters et al & Fuss et al.

EPT of concern in patients with cardiac pace makers

TEST CAVITY
Non localized, acute diffuse radiating pain
Definitive diagnosis: impossible
Cavity prepared in the tooth without anesthesia
Patient apprised of what to expect & how to respond
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
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.
LASER DOPPLER
FLOWMETRY
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
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
 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
PULSE OXIMETRY
Effective, objective oxygen saturation monitoring technique –
intravenous anesthesia
Consistently determined the level of blood oxygen saturation of
the pulp- pulp vitality testing

Custom-made Pulse
Oximeter sensor
holder (Gopikrishna et
Biox 3740 Oximeter al 2006)
(Kahan et al 1996)

Correlation between
pulp and systemic
oxygen saturation
readings (Schnettler
•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

 Limitations:
Intrinsic interference:

venous blood &

Indications: tissue constituents,
Recent trauma
acidity,CO2
Primary &
Extrinsic interference
immature
Hb bound to other
permanent teeth
gases

Extensive restorations

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)
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
ULTRAVIOLET
LIGHT/FIBEROPTIC
FLUORESCENT SPECTROMETRY
Fluorescence
Vital teeth fluoresce normally; necrotic & RCT teeth do not
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
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
TOOTH SURFACE
TEMPERATURE
pulp circulation maintains tooth temperature
Hughes Probeye

Electronic 4300 thermal

Thermistor
Thermography video

system
Infrared sensor,control unit,thermal
image computer,software,color sensitive to measure 0.1oc
monitor,printer

Cholesteric crystals:10% solution in

chlorinated hydrocarbon
solvent(Howell et al)- non vital
Patient temperature

Baseline temperature: follwed up

Differences in superficial areas not
Patient is improving/ worsening
sensitive
>1000oF : systemic response to
infection
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
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
OPTICAL REFLECTION
VITALOMETRY
Noninvasive method
The pulse of the pulp/oral mucosa.
Yet to be clinically accepted & commercially available.
RADIOGRAPHY-LITTLE VALUE

Presence & extent of carious lesions

Calcifications
Resorptions
Periradicular status
Tracing fistulous tracts
Thickness of PDL
Periodontal disease
Root & pulp space anatomy
Previous RCT
DIGITAL RADIOGRAPHY

Digital radiography
Variables in diagnostic quality of
conventional radiography- controlled
Image- enhanced, colorized and useful
patient education tool
CBCT

First used in dentistry- Mozzo P et al 1998

3 D representation in image acquisition
Proximity to anatomic structures
Root canal anatomy
REFERENCES
Weine F . 6th ed. 2003.Endodontic therapy. Mosby publications
Ingle et al.6th ed. 2008..Endodontics.BC Decker Inc
Cohen’s Pathways of the Pulp- 10th ed
Grossman.13th ed.2015.Endodontic practice. Wolters kluver
Endodontics- Problem solving in Clinical practice- Pitt Ford
Practical Endodontics- A clinical guide. Bessner & Ferrigno
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
‘‘FOR I SEEK THE TRUTH BY
WHICH NO MAN HAS EVER BEEN
HARMED.’’
—MARCUS AURELIUS,
MEDITATIONS VI. 21, 173 AD