7/27/2019 diagnosis 5.pdf

1/20

/12/1434

Dent 423; Diagnostic Tests IAceil Al-Khatib DDS, MS, Diplomat

ABOM

Routine Dental Tests Vitality tests:

Thermal: cold and heat

Electrical

Cutting an access cavity without

anaesthesia

7/27/2019 diagnosis 5.pdf

2/20

/12/1434

Vitality Tests

Provide an adjunct to determining the state of

pulp

Results must be interpreted with caution

False positive and false negative results are

common

Vitality tests

Surrounding and contralateral teeth should

also be tested

Test should begin on a normal tooth

Stimuli should be applied to normal enamel of

the crown of the tooth

Better results ifmore than one test is used (

heat and cold, or cold and electrical tests)

7/27/2019 diagnosis 5.pdf

3/20

/12/1434

Uses Of Vitality Testing In Clinical

Practice

Prior to operative procedures

Diagnosis ofpain

Investigation ofradiolucent areas

Post-trauma assessment

Assessment ofanaesthesia

Assessment of teeth which have been pulp

capped or required deep restoration

Thermal Vitality Tests

A temperature in the range of20-50 C does

not elicit pain from healthy teeth

Teeth with inflamed pulps (pulpitis) react with

severe pain on temperature stimulation within20-50

7/27/2019 diagnosis 5.pdf

4/20

/12/1434

Cold Test

Involves using a refrigerant, such as endo-ice,

ethyl chloride spray

The middle third of the clinical crown for

posterior teeth and the border between the

coronal and middle thirds of the clinical crown

for anterior teeth

How to Apply the Cold Test

Hold a cotton pellet in tweezers

Spray Ethyl chloride or endo ice until crystals

form

Apply the icy pellet to the facial surface of the

tooth

Leave the chilled cotton pellet on the tooth for

at least 10 seconds before deciding on the

response

7/27/2019 diagnosis 5.pdf

5/20

/12/1434

7/27/2019 diagnosis 5.pdf

6/20

/12/1434

7/27/2019 diagnosis 5.pdf

7/20

/12/1434

The Heat Test

Apply to the vaseline-coated surface of thetest tooth

Use a ball of softened gutta percha on the tipof a plastic instrument (gutta-percha softensat 65 C)

Place the gutta percha onto the tooth thesame way you would the ice

Wait approximately 5 seconds

Compare the results from other tested teeth

7/27/2019 diagnosis 5.pdf

8/20

/12/1434

A rubber cup applied to a tooth to generatefrictional heat

The use of hot water,

administered

through an irrigating

syringe under rubber

dam isolation

7/27/2019 diagnosis 5.pdf

9/20

/12/1434

Disadvantages

May be difficult to use on posteriorteeth because oflimited access

Excessive heating may result in pulp damage

May result in a lingering pain, therefore heattests should be applied for no more than 5seconds

Inadequate heating of the gutta-percha stick

could result in the stimulus being too weak toelicit a response from the pulp

Electric Pulp Test (EPT)

EPT is technique-sensitive

The tooth must be clean and dry

The anatomic location should have norestoration, orthodontic band or brackets, orarch wire

An adequate medium ( gel, toothpaste)shouldbe applied having contact between the toothprobe and tooth for a completed electricalcircuit

7/27/2019 diagnosis 5.pdf

10/20

/12/1434

Before beginning, provide the patient with

specific instructions to raise a hand or arm

when a sensation occurs

Clean , dry and isolate the tooth

Use a small amount oftoothpaste on the

metal tip of the probe

Place the tip on the middle of the facialsurfaces of the tooth

How To Conduct The EPT

Do not place the probe on a restorative

material (metal, composite, ceramic) or touch

gingival tissues

The probe should not touch lips or cheeks

Have the patient touch the handle of thedevice with a finger ( in order to ground the

unit to complete the electric circuit)

Start by pressing and holding the start button

How To Conduct The EPT; Contd

7/27/2019 diagnosis 5.pdf

11/20

/12/1434

Gradually increase the voltage until aresponse is elicited

When the patient indicates a response,release the start button

The reading will be fixed on the display forsome time after the button is released

A response to the maximum reading (e.g.

reading of 64 is usually indicative that the pulpof the tooth being tested is nonvital)

How To Conduct The EPT; Contd

Between 0-40, the

patient feels ache;

vital pulp

Between 40-

80,with above-

mentioned

reaction, partially

vital pulp

80, no mentioned

reaction, non-vital

pulp

7/27/2019 diagnosis 5.pdf

12/20

/12/1434

7/27/2019 diagnosis 5.pdf

13/20

/12/1434

A hook on the patients lip completes

the circuitElectrical conducting gel is presentbetween the electrode and thetooth

This test should be used when the hot andcold tests fail to give clear information on thestate of vitality of the tooth

Results must be compared with the responsefrom other teeth

The most desirable area of assessment is atthe incisal edge of incisor teeth, and the mid-third region of posterior teeth (on the tip ofthe mesiobuccal cusp on molars )

Electric Pulp Test (EPT)

7/27/2019 diagnosis 5.pdf

14/20

/12/1434

False Positives From EPT Testing

Anxious patients

Liquefaction necrosis

Contact with metal restorations

Vital tissue still present in partially necrotic

root canal system

Incomplete root development

Recently traumatized teeth

Sclerosed canals

Recent orthodontic activation

Patients with psychotic disorders

False Negatives From EPT Testing

7/27/2019 diagnosis 5.pdf

15/20

/12/1434

Interpretation Of The Results Of

Vitality Tests; Positive ( Normal)

The test tooth responds in a similar way and

to a similar level of stimulation to the other

healthy teeth.

This result suggests that the pulp is vital

The test tooth responds more severely than

and to a lower level of stimulation to the

other healthy teeth.

Pain lasts for more than some 15 seconds (

minutes, hours) after removal of the stimulus The response to heat & electrical stimulation

may be greater than to cold.

Cold may reduce the pain

Interpretation Of An Exaggerated(prolonged) Response

7/27/2019 diagnosis 5.pdf

16/20

/12/1434

Irreversible pulpitis

Chronic pulpitis; if gradual reaction to heat,

but not to cold or electrical stimulation leads

to an exaggerated response

Interpretation Of An Exaggerated

(prolonged) Response

The test tooth does not respond to

stimulation but healthy teeth do

The result suggests:

Non- vital pulp

Root canals are sclerosed

Interpretation Of Negative Response

7/27/2019 diagnosis 5.pdf

17/20

/12/1434

The test unhealthy tooth responds normally;

Occur in anxious or young patients

Contact with metal restorations (electric test)

Inadequately dried teeth ( electric test)

Multi rooted teeth with one vital root canalpulp

In a root canal filled with pus or gas

In a patient with low pain threshold

False Positive

False Negative

Teeth with restorations ( heat and cold test)

Teeth with secondary dentine

Nerve supply to the pulp is damaged (e.g.

trauma)

In a patient with a high pain threshold

Faulty technique or equipment

7/27/2019 diagnosis 5.pdf

18/20

/12/1434

Inconclusive Result

All teeth give similar responses: conflictive

results

If the results of two tests are inconclusive add

a third test

Consider cutting a diagnostic access cavitywithout local anaesthesia

Diagnostic Cavity Preparation

Is the most reliable vitality test

This test may serve as a last resort in testingfor pulp vitality

Is made by drilling through the enameldentine junction of an unanaesthetized toothwith good isolation

If the patient feels pain once the bur contactsthe sound dentin, the procedure is terminatedand cavity is restored

7/27/2019 diagnosis 5.pdf

19/20

/12/1434

Local Anaesthetic Test

When dental symptoms are poorly localized orreferred, an accurate diagnosis is extremelydifficult

Using either infiltration or an intraligamentaryinjection, the most posterior tooth in the areasuspected of causing the pain is anaesthetized

If pain persists, the tooth immediately mesial

to it is then anaesthetized, and so on, until thepain disappears

Assessment Of Pulpal Vascularity

Crown surface temperature

Laser Doppler flowmetry: a non-invasive ,

painless technique with direct and objective

registrations, but has limitations : environmental

and technique-related factors. Nonpulpal signals,

principally from periodontal blood flow, may

contaminate the signal

Pulse oximetry: measure oxygen saturation levels

7/27/2019 diagnosis 5.pdf

20/20

/12/1434

A LDF probe applied to a sectioned tooth

showing the passage of light via the enamel

prisms and dentinal tubules to the pulp

Laser Doppler Flowmetry (LDF)

A LDF trace showing signals from

two teeth; the upper is from a vital

tooth while the lower is from a

nonvital tooth