Asallam Alekkum

Dr. Gaurav Garg, Lecturer

College of Dentistry, Al Zulfi

Diagnosis ?

Diagnosis is a process of determining the nature of a disease.

very important for proper treatment.

Differential diagnosis is the process of differentiating between similar diseases.

For correct differential diagnosis:

Proper knowledge of the disease

Skill and Art on how to apply proper diagnostic methods

A good clinician has to be a good

diagnostician.

Qualities of a good diagnostician-

Knowledge

Interest

Intuition

Curiosity

Patience

As stated by Grossman, are phenomenon or

signs of a departure from the normal, and are

indicative of an illness.

Types:

1. Subjective Symptoms are those which are

experienced and reported to the clinician by the

patient.

2. Objective Symptoms are those, which are

obtained by the clinician through various tests.

Lingering tooth sensitivity to cold liquids.

Lingering tooth sensitivity to hot liquids.

Tooth sensitivity to sweets.

Tooth pain to biting pressure.

Tooth pain that is referred from a tooth to another area, such as the neck, temple, or the ear.

Spontaneous toothache, such as that experienced while reading a magazine, watching television, etc.

Constant or intermittent tooth pain.

Severe tooth pain.

Throbbing tooth pain.

Tooth pain that may occur in response to postural changes, such as when going from a standing to a reclining position.

Good case history:

Chief complaint

Past medical history

Past dental history

Also includes vital signs, history of presenting illness.

• It is essential to gather collective information regarding signs, symptoms, and history for a successful outcome of any treatment procedure.

Thorough clinical examination

Relevant investigations / diagnostic tests

Hardly exists any contraindication except:

Uncontrolled Diabetes

A very recent Myocardial infarction

Aid the dental clinician in deciding whether a

prior medical consultation or pre-medication

(chemo-prophylaxis) would be required

Cardiovascular:

High & moderate risk of Endocarditis

Pathologic heart Murmers

Hypertension

Unstable angina

Recent myocardial infarction

Arrythmias

Poorly managed congestive heart failure.

Pulmonary:

COPD

Asthma

Tuberculosis

GI & Renal:

End stage renal disease , Hemodialysis

Viral hepatitis( B,C,D,E)

Alcoholic liver disease

Peptic ulcer disease

Endocrine & Hematologic:

STDs, HIV & AIDS

Diabetes mellitus

Adrenal insufficiency

Hyperthyroidism

Pregnancy

Bleeding disorders

Cancer & leukemia

Osteoarthritis, rheumatoid arthritis, SLE.

NeurologicDisorders

Side effects of medications:

Stomatitis, xerostomia, petechiae, ecchymosis, lichenoidlesions & mucosal & gingival bleeding.

Lymphoma or Tuberculous involvement of cervical & submandibular lymph nodes

Immunocompromised & patients with uncontrolled Diabetes

Patients with iron deficiency anaemia, pernicious anemia & leukemia frequently exhibits paraesthesia of oral soft tissues complicating making a diagnosis when other dental pathosisis also present in the same area of the oral cavity.

Sickle cell anemia has the complicating factor of bone pain, which mimics odontogenic pain & loss of trabecular bone pattern on radiographs which can be confused with radiographic lesions of endodontic origin.

Multiple myeloma can result in unexplained mobility of teeth.

Radiation therapy to head & neck region can result in increased sensitivity of teeth & osteoradionecrosis

Trigeminal neuralgia, referred pain from cardiac angina, and multiple sclerosis can also mimic dental pain.

Acute maxillary Sinusitis- a condition that may mimics tooth pain in maxillary posterior quadrant. In this situation the teeth in the quadrant will be extremely sensitive to cold & percussion, thus mimicking the signs & symptoms of Pulpitis.

Chief complaint is the best starting point for a

correct diagnosis

PAIN is one of the most common chief

complaints encountered

In order to attain a detailed knowledge regarding pain, following questions may be necessary:

1. Type of pain :

Grossman has stated Pulpal pain to be of the following two varieties :

Sharp, piercing and lancinating -- a painful response usually associated with the excitation of the A-DELTA nerve fibers. This pain usually reflects REVERSIBLE state.

Dull, borinq, gnawing and excruciating-- a painful response usually associated with the excitation of C-nerve fibers.

Usually reflects an irreversible state of pulpitis.

2. The duration of pain:

When the pain is of a shorter duration (1

minute)-Reversible Pulpitis - Excellent chance

of recovery without the need for endodontic

treatment

Whereas when the pain is of a longer duration,

it is considered to be Irreversible Pulpitis

3. The localization of pain:

Sharp piercing pain can usually be localized and responds to cold

Dull pain usually referred / spread over a larger area responds more abnormally to heat

Patients may report that their dental pain is exacerbated while lying down or bending over

This occurs because of the increase in blood pressure to the head, which therefore increases the pressure onthe confined pulp

4. Factors which provoke/ relieve pain:

Response to a provoking factor (e.g. on

mastication) indicates pulp vitality, but

stimulation causing extended severe pain

suggests irreversible pulpitis.

Thus pain, which is recorded as the complaint

is considered to conclude an acute or chronic,

reversible or irreversible condition of the pulp.

Characterized by pain which is of a :-

Shorter duration

Localized

May be piercing/ lancinating in nature

More responsive to cold than heat

Caused by a specific irritant & disappears as

soon as it is removed

Abnormal dental pain, which responds to heat

Which occurs on changing the position of the

head, awakening the patient from sleep

Dull pain of Longer duration, which occurs

during mastication in a Cariously exposed

tooth

History Slight sensitivity or

occlusal pain

Constant or intermittent pain

Pain Momentary &

immediate, sharp in

nature & quickly

disappears thereafter

Continuous, Delayed onset,

throbbing, persists for minutes to

hours after removal of stimulus

Location of pain May be localized & is

not reffered

Pain is not localized. If it is

localized, its only after periapical

involvement. Pain is reffered.

Lying down No difference Pain increases

Thermal test Responds Marked & prolonged

E.P.T. Early response Early, delayed or mixed response

Percussion Negative Negative in early stages. Later

positive when periapex is

involved

Radiography Negative May show widening of PDL space

The clinician should look for:

Facial asymmetry

Localized swellings

Lymphadenopathy

Changes in color, bruises/ scars, similar signs of disease, trauma or of any various treatment.

Begins with a general evaluation of the oral

structures.

The occlusion is checked (for any

derangements if any)

The lips, cheeks, vestibules and mucosa are

examined for any evident abnormalities.

Several tests are employed in order to

determine the condition of teeth and supporting

structures.

Simplest and the easiest of the diagnostic tests

Acc. To Grossman the prime objective of visual & tactile inspector is evaluation of the “3 C’s” viz:

Color

Contour

Consistency of hard and soft tissues.

Soft tissue:

Color- the normal color of gingiva is coral pink. Change from this is easily visualized in inflammatory conditions.

Contour- change in normal contour (eg, of scalloped gingiva) occurs with a swelling.

Consistency- On inspection (most commonly gingiva) appears healthy, firm, resilient, while a soft, fluctuant or spongy tissue is more indicative of a pathological state.

Hard tissue:

A similar parameter of the visual and tactile inspection., ie, of the “C’s’is employed for the dental tissues as well.

Color- Normal teeth show life like translucency & sparkle that is missing in pulpless teeth which appear more or less opaque. Note: This discoloration however could be due to a variety of other reasons like old amalgam restorations, tetracycline stains etc.

Contour- This examination should also include the visualization of contours of affected teeth, such as fractured teeth, wear facets, improperly contoured restorations, or altered crown contours as these factors can have a marked effect on the respective pulps.

Consistency- Change in the consistency of hard dental tissues is related to the presence of caries, external and internal resorption

The visual and tactile inspection is usually carried out with a mouth mirror, explorer and a periodontal probe under dry conditions with good illumination source.

A general visual examination of the entire mouth should be made to ascertain whether the tooth requiring treatment is a strategic tooth

Before percussing the involved tooth, instructions are to be given to the patient to raise his/ her hand or make an audible sound in order to let the clinician know when and whether the tooth feels “TENDER”, “DIFFERENT” or painful on percussion.

Before percussing the teeth with the handle of the instrument (a mouth mirror etc), the quadrant of the involved tooth is percussed using the index finger with quick blows of low intensity.

The teeth should be tapped (with the index finger) in a random fashion so that the patient cannot “anticipate” when the tooth will be percussed

When no response is elicited on digital percussion, then the handle of an instrument is to be used/employed.

Percussion is done in both vertical and horizontal directions.

Change the sequence of percussion in successive tests to eliminate bias.

The force of percussion should only be strong enough for the patient to differentiate between a sound tooth and a tooth with inflamed periodontal ligament.

The proprioceptive fibers in an inflamed periodontal ligament will, when percussed, help the patient and the clinician locate the source of pain.

Positive response is indicative of periodontitis (pericementitis) which could be due to:

Teeth undergoing rapid orthodontic movement.

High points in recent restorations.

Lateral periodontal abscess.

Partial/total Pulpal necrosis.

Negative response may be seen in cases of

Chronic periapical inflammation

Usually

* Dull note- Signifies abscess formation. * Sharp note- denotes Inflammation.

* Metallic note- Ankylosis.

Employs the usage of the (index finger) fingertip, supplemented with a light digital pressure to examine tissue consistency and pain response.

The importance of this test other than as an aid in locating the swelling over an involved tooth, is in determining the following:

Whether the tissue is fluctuant and enlarged sufficiently for incision and drainage.

The presence, intensity and location of pain.

The presence and location of Adenopathy

The presence of bony Crepitus.

To evaluate the integrity of the attachment apparatus surrounding the tooth.

Moving the involved tooth laterally in socket using handles of two instruments or more preferably using two index fingers.

The test for Depressibility is similar and is performed by applying pressure in an apical direction on the occlusal/incisalaspect of tooth and observing vertical movement if any.

GROSSMAN AND COHEN:

GRADE I. [First degree] - Noticeable/ barely discernable movement of the teeth within its sockets.

GRADE-II. [Second degree] - .Lateral/ horizontal mobility within a range of 1 mm or less.

GRADE III [Third degree]-Movement greater than 1 mm or when the tooth can be depressed into the socket.

MILLER:

0 - Non mobile/ mobility within physiologic limits.

1 - Mobility within range of 0-0.5mm.

2 - Mobility within range of 0.5-1.5mm with lateral movements.

3 - Mobility more than 1.5 mm with lateral movements and can be Intruded/depressed into the socket.

Periodontal examination- a must

Furcation involvement.

A lateral canal - portal of entry for

toxins- Pulpal degeneration.

Thermal and electric pulp tests

must be performed along with

periodontal examination to

distinguish between disease of

Pulpal and Periodontal origin.

Assess the state of the pulp.

Based on the Hydrodynamic Theory as postulated by Brannstrom (1963).

Heat Test

Cold Test

A response to cold - a vital pulp regardless of whether it is normal or abnormal- Grossman.

A heat test does not confirm vitality.

An abnormal response to a heat test however exhibits presence of a pulpal or peri apical disorder requiring endodontic treatment.

when a reaction to cold occurs the patient can quickly point out to the painful tooth, unlike in a heat test situation where the response could be localized, diffused or even referred to a different site- Grossman.

The results should be co-related with other tests to ensure validity.

Explain the manner and procedure to the patient and also the kind of sensation he/she may experience.

First on control teeth- placing the stimuli on the Inciso-Labial (anterior) surface or the Occluso-Buccal(posterior) surface.

Guides the clinician to evaluate the difference in response, the affected tooth provides.

Helps the patient understand better the nature of the stimulus he/she would experience.

Exposed dentinal surfaces and restored surfaces should be avoided.

Isolation of the quadrant to be tested

The preferred temperature, however, for

performing a heat test (according to Cohen) is

65.5ºC or 150F.

The heat test can be performed using different techniques such as:

1. Hot air 2. Hot water 3. A hot burnisher4. Hot gutta-percha 5. Hot compound 6. Polishing of crown with a rubber cup

Isolating the quadrant with the tooth to be tested.

Cold application can be performed in any of the following ways viz.

A stream of cold air from a 3-way syringe directed against the crown of previously dried tooth.

Use of ethyl chloride spray (which evaporates rapidly ) absorbing heat and cooling the tooth surface (-55ºC).

Ice Stick

CO2 snow

The patient’s response to heat and cold tests are identical because the neural fibers in the pulp transmit only the sensation of pain (Hydrodynamic theory -Brannstorm).

There are four possible reactions, that the patient may experience,

1. No response - may be non vital or vital but giving a false-negative response due to excessive calcifications, immature apex, recent trauma, patient medication etc.

2. Painful response- which subsides when stimulus is removed from the tooth- Reversible- pulpitis.

3. Moderate, transient response- Normal.

4. Painful response- which lingers after removal of stimulus-Irreversible Pulpitis.

•Bender IB et al (1989), J Am. Dent. Assoc : 118; 305-310

•Pulpal Diagnosis, Endodontic Topics 2003, 5, 12-25

•Jack Lin et al (2007) JOE ; 33: 11

Historically, the E.P. tester has been used in dentistry as early as 1867.

Designed to stimulate a response by electrical excitation of the neural elements within the pulp.

Does not provide any information regarding the vascular supply to the tooth.

Considered advantageous when compared with the thermal tests since the quantitative readings are obtained which can be compared with that of a later test (when conducted).

Test should be first described to the patient .

Teeth to be tested should be isolated with cotton rolls, saliva ejector and air dried.

Check the E.P. tester for proper functioning.

Apply an electrolyte on the tooth surface (Nicholls-colloidal graphite, Grossman-tooth paste).

Avoid contact of the electrolyte or electrode with any restorations or the adjacent gingival tissue as this could lead to a false response.

Retract the patient’s cheek or lip with free hand, away from the tooth electrode.

* Bender IB et al (1989), J Am. Dent. Assoc : 118; 305-

310

* Pulpal Diagnosis, Endodontic Topics 2003, 5, 12-25

* Jack Lin et al (2007) JOE ; 33: 11

Intensity of stimulus is comfortable to the patients.

The digital display of many E.P.Testers provide

instant, easy and reliable information.

In some E.P. Testers, a red indicator light flashes

on and off when maximum stimulus is reached.

Gives a quantitative reading and can be compared

with the normal reading of control tooth.

Cannot be used on patients having cardiac pace maker.

Some E.P.T equipments are very expensive.

E.P.T is not useful for recently erupted teeth with immature apex. This may be because the relationship between the odontoblasts and the nerve fibers of the pulp has yet to develop (Nicholls).

Recently traumatized teeth cannot be tested.

No indication is given regarding state of the vascular supply which would give a more reliable measure of the vitality of the pulp.

Readings from posterior teeth with partially vital pulps may be misleading.

A. False Positive Responses: When the pulp is necrotic but patient gives a positive response.

B. False Negative Responses: When the pulp is vital, but the patient is unresponsive to the E.P.T.

Reasons for False Positive Response:

Conductor / electrode in contact with a metallic restoration or gingiva along with the current to reach the attachment apparatus.

Patient anxiety.

Liquefaction necrosis-This may conduct the current to the attachment apparatus and the patient may slowly raise his hand near the highest range.

Failure to isolate or dry the teeth

In multi-rooted teeth where the pulp may be partially necrotic.

Reasons for a False Negative Response:

Patient heavily pre-medicated with analgesics, narcotics, alcohol, tranquilizers.

Inadequate contact with enamel.

Recently traumatized tooth.

Excessive calcification in the canal.

Recently erupted tooth with an immature apex. This according to Nicholls, may be because the relationship between the odontoblasts and nerve fibers of the pulp has yet to develop.

The results obtained / tabulated through the E.P. T conducted should not be thoroughly relied upon. These results should be co-related with those obtained with other vitality tests such as the thermal tests etc.

Laser Doppler flowmetery

Pulse Oximetery

Restricted to patients who are in pain at the time of the test and when the usual tests have failed to help identify or localize the offending tooth.

The objective is to anesthetize a single tooth at a time until the pain disappears and is localized to specific tooth.

infiltrate the posterior most tooth in the suspected zone.

If pain persists anesthetize the next tooth mesial to it and continue to do so until the pain disappears.

If the source of pain cannot be differentiated ie. ,maxillary / mandibular, then mandibular block is implemented.

further localization of the affected tooth is done by an intraligamentary injection, once the anesthetic has spent itself.

one of the last resorts in localizing the offending tooth.

last resort

The cavity is prepared by drilling through DEJ of an unanesthetized tooth at a slow speed and without a water coolant.

Sensitivity and pain elicited by the patient is an indication of the pulp vitality.

A Sedative cement is then placed in the prepared cavity and the search for the cause of pain may be continued.

On the contrary, if no pain/sensitivity is recorded, the cavity preparation may be continued until the pulp chamber is reached and if the pulp is noticed to be necrotic, routine endodontic treatment could be performed.

Light from a fiberoptic is

applied from the buccal

surface to illuminate the

tooth to detect the

fractured lines when

present

An orangewood stick is placed on the occiusal/incisalaspect (on each cusp in case of posteriors) of the tooth and the patient is asked to bite.

To identify the fractured tooth /cracked tooth syndrome.

1. Remove the filling from the suspected tooth and place 2% Iodine in the cavity preparation.

* The iodine stains the fracture line dark.

2. Mix a dye with zinc-oxide eugenol and place it in the cavity preparation after filling has been removed.

* The dye will seep out and color the fracture line.

3. Have a patient chew a disclosing tablet after taking out the filling in the suspected fractured tooth.

* The line will be stained.

Can localize the endodontic lesion to the specific tooth.

Aids in the differential diagnosis between a periodontal and an endodontic lesion.

Placing a gutta perchapoint through the sinus/fistula tract and take a radiograph.

Provides information on the extent of caries in to the pulp

No. of root canals and accessories

The course & shape of the canals

Length of the root

Calcifications

Resorptions

PDL status

Nature of periapicalarea & alveolar bone

Root fractures

Differentiation of pathosis

Location of perforations

Post obturation

evaluation

Evaluate healing

after RCT

Medico legal

records

State of pulpal health can not be ascertained

P/A pathology is evident only after much destruction(33%)

Vertical root fracture can not be diagnosed

Bony trabculae misinterpreted for horizontal root #

Extend of caries is usually less than the actual extent as is true for P/A pathology

Xeroradiography

Radiovisiography (RVG)

Cone beam computerized tomography (CBCT)

Magnetic Resonance Imaging (MRI)

Ultrasound imaging

REFERENCES:

1. COHEN-Pathways of the Pulp (Ninth Edition)

2. GROSSMAN- Endodontjc Practice (Eleventh Edition)

3. INGLE-Endodontjcs (Fourth Edition)

4. WEINE-Endodontic Therapy (Fifth Edition)

5. Technical equipment for assessment of dental pulp status(Endodontic Topics 2004, 7, 2–13).

6. Pulpal diagnosis (Endodontic Topics 2003, 5, 12–25).

7. Classification, diagnosis and clinical manifestations of apical periodontitis(Endodontic Topics 2004, 8, 36–54)