Diagnostic Procedures / orthodontic courses by Indian dental academy

8/12/2019 Diagnostic Procedures / orthodontic courses by Indian dental academy

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DIAGNOSTIC PROCEDURES

Introduction

Correct treatment begins with a correct diagnosis. Arriving at a right

diagnosis requires knowledge, skill and art.

The dictionary defines diagnosis as the art of identifying a disease

from its signs and symptoms.

Symptoms are units of information sought in clinical diagnosis.

Symptoms are defined as phenomena signs of a departure from the

normal and indicative of illness.

Symptoms can be classified accordinly!

Sub!ective symptoms " are those e#perienced and reported to the

clinician by the patient.

$b!ective symptoms " are those ascertained by the clinician through

various tests.

%any diseases have similar symptoms. &ence the clinician must be

astute in determining the correct diagnosis.

Differential Dianosis!

This technique distinguishes one disease from several other similar

disorders by identifying their differences.

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(iagnosis by e#clusion on the other hand, eliminates all possible

diseases under consideration, until one remaining disease correctly

e#plains the patients symptoms.

T"us t"e criteria for on accurate clinical dianosis includes!

a good case history

a thorough clinical e#amination

relevant investigations diagnostic tests

#edical $istory!

)ven though there are virtually no systemic contraindicatios to

endodontic therapy *e#cept uncontrolled diabetes or a very recent

myocardial infarction+, a recent and succinct, comprehensive medical

history is mandatory.

t is only with such a history that the clinician can determine

whether medical consultation or premedication is required before

diagnostic e#amination or clinical treatment is undertaken.

Some patients require antibiotic prophyla#is before clinical

e#amination because, of systemic conditions like"

&eart value replacement

A history of rheumatic fever

Advanced A(S

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n case of patients who daily take anticoagulant medication may

need to have the dose reduced or dosing suspended, especially in case of a

periodontal e#amination.

hen patients report being infected with communicable diseases

such as A(S, tuberculosis, &epatitis /, dentists and staff must use

protective barriers.

The clinician must also know what drugs the patient is taking so

that adverse drug reactions can be avoided.

0atients who present with mental or emotional disorders are not

uncommon. n these cases too, medical consultation before the diagnostic

e#amination would be in the best interests of the patient, (octor and Staff.

Dental $istory!

After completing, the medical history, the clinician should develop the

dental history.

The purpose of a dental history is to create a record of the chief

complaint, the signs and symptoms the patient reports, when the problem

began and what the patient can discern that improves worsens the

condition.

The most effective way for the clinician to gather this important

information is to ask the patient pertinent questions regarding the chief

complaint and listen carefully and sensitively to the patient responses.

/ecause dental pain frequently is the result of a diseased pulp, it

is one of the most common complaints.

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hatever the reason, the patients chief complaint is the best

starting point for a correct diagnosis.

Subjective Symptom" As mentioned before 0A2 is a sub!ective symptom.

3udicious questioning of the pain can aid the

diagnostician in developing a tentative diagnosis quickly.

$ne should ask the patient the following"

the kind type of pain

4ocation of the pain

(uration of the pain

hat causes the pain

hat alleviates it

hether it is referred to another site or not

Type / Kind of pain" 5enerally pulpal pain is described by the patient in one of

the - ways.

*a+ Sharp, piercing and lancinating 6 due to the e#cition of the A7delta8

nerve fibres *myelinated principal sensory fibres+ in the pulp. This pain

may reflect on a reversible state of pulpitis.

*b+ (ull, boring, growing and e#cruciating pain" due to e#citation and

shower rate of transmission of the C8 nerve fibres *unmyelinated

fibres+.

This pain usually reflects on 99):)9S/4) STAT) $;

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Duration of pain!

At times pulpal pain lasts only as long as an irritant

is present.

At other times, it lasts for minutes to hours.

n case of Acute reversible pulpitis.

0ain 6 short duration 6 disappears soon after

removal of the stimulus.

Sharp, lancinating and piercing

ed

s more responsive to cold than to heat.

n case of irreversible pulpitis,

0ain 6 persists even after removal of the stimulus or irritant.

(iffuse.

4onger duration.

9esponds abnormally to heat than to cold.

%ocali&ation of pain!

0ain is locali>ed when the patient can point to spot a specific tooth or

site with assurance and speed when asked to do so.

e and responds

promptly to cold.

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hen the pain is diffuse, it relates to a dental pain that is dull, boring

and gnawing.

This pain can also be referred to other sites.

Referred pain" At times pain is referred to other areas and even beyond the

mouth.

%ost commonly it is manifested in other teeth in the same or the

opposing quadrant.

&owever, referred pain is not necessarily limited to the other teeth. t

may, for eg. be ipsilaterally referred to the preauricular area, or down

the neck or up the temporal area.

n these instances the source of e#traorally refereed pain almost

invariably is a posterior tooth.

0atients may report that their dental pain is e#acerbated by lying down

or bending over.

This occurs because of the increase in blood pressure to the head, which

increases the pressure on the confined pulp.

Abnormal dental pain caused by heat usually requires endodontic

treatment.

0ain that occurs on changing the position of the head, awakens the

patient from sleep, or occurs during mastication of food in a cariously

e#posed tooth usually indicates a need for treatment.

Acute Re'ersible Pulpitis Irre'ersible Pulpitis

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Pain:

Sharp,laminating, piercing.

Short

duration 6 disappears soon after

removal of the stimulus.

%ore

responsive to cold.

ed.

(ull,

boring, growing e#cruciating pain

longer duration.

0ersists

even after removal of the stimulus

irritant.

9esponds

abnormally to heat them to cold.

(iffuse.

Ob(ecti'e Symptoms!

$b!ective symptoms are determined by tests and observations

performed by the clinician.

These tests are as follows" Commonly used tests

'. :isual and tactile inspection

-. 0ercussion

1. 0alpation

=. %obility and depressibility

?. 9adiographs

@. Thermal tests

. )lectric pulp test

B. 0eriodontal e#amination

. Test cavity

'D. Anesthesia test

''. $cclusal pressure test


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'-. 5utta7percha point tracing

'1. Transillumination

'=. Staining

Special #et"ods!

'. Eero 6 radiography

-. 0ulse 6 o#imetry

1. 4aser 6 (oppler flowmetry

=. Computeri>ed Tomography

?. (igital subtraction radiography

@. %.9..

. 9.:.5.

B. Computeri>ed e#pert system

1. Visual and Tectile Inspection" This is one of the most simplest clinical

tests.

Too often, it is done only causally during e#amination, and as a

result, much essential information is lost inadvertently.

A thorough visual, tactile e#amination relies on checking the

1Cs8 7 Colour, Contour, Consistency.

In case of soft tissues" such as gingiva 6 any deviation from the healthy, pink

colour is readily recogni>ed when inflammation is present.

ontour" a change in contour occurs when there is swelling.

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onsistency" a change in consistency from normal, healthy firm tissue to that

of a soft, fluctuant or spongy tissue indicates a pathologic condition.

In case of !ard tissues"even the hard tissues i.e. the teeth should be visually

e#amined using the 1 Cs8.

olour" a normal appearing crown has a lifelike translucency and sparkle that

is missing in pulpless teeth.

Teeth that are discoloured, opaque and less lifelike in appearance

should be carefully evaluated.

/ecause the pulp may already be inflammed, degenerated or necrotic.

2ot all the discoloured teeth will require endodontic treatment.

Staining maybe caused by old amalgam restorations, root canal

filling materials and medicaments, or systemic medication, such astetracycline staining.

%any discolourations, however, are the result of disease

commonly associated with nectrotic and gangrenous pulps, internal or

e#ternal resorption, carious e#posure.

ontour" crown contours should be e#amined.

Causes for changes in the crown contour could be:

;ractures

ear facets

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The clinician should be prepared to evaluate

the possible effects of such changes on the pulp.

onsistency" of the hard tissue relates to the presence of caries and internal or

e#ternal resorption.

Techni#ue" the technique of visual and tactile e#amination is simple.

t can be done with oneFs fingers, an e#plorer and the periodontal probe.

The patients teeth and periodontium should be e#amined in good light

under dry conditions.

For Example" a sinus tract *fistula+ might escape detection if it is covered by

saliva or an interpro#imal cavity may escape notice if it is filled with food.

4oss of translucency, slight colour changes and cracks may not be

apparent in poor light *in such cases, a trasilluminator may aid indetecting enamel Cracks Crown Gs+

:isual e#amination should also include the soft tissues ad!acent to the

involved tooth, for detection of swelling.

The crown of the tooth should be carefully evaluated, to determine

whether it can be restored properly after completion of endodontic

treatment.

;inally, a rapid survey of the entire mouth should be made, to ascertain

whether the tooth requiring treatment is a strategic tooth.

)* Percussion!

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n percussion, the crown of a tooth is tapped with the tip of a finger or

with an instrument.

A painful response to percussion denotes inflammation of the

periodontal membrane.

Although percussion is a simple method of testing, it may be

misleading if used alone.

n performing the test, several teeth are percussed in a random order, toeliminate bias on the part of the patient.

nitially a suspect tooth should be tapped very gently, since the

periodontal membrane maybe e#tremely tender. f there is no response

a sharp tap is given.

$ne should change the direction of the blow from the vertical occlusal

to the buccal or lingual surfaces of the crown and strike separate cusps

in a different order.

t must be born in mind that tenderness to percussion does not

necessarily denote pulpal disease.

A tooth with a healthy pulp may develop on acute apical periodontitis

from a blow or premature occlusal contact.

or an acute periodontitis maybe the sequel to food packing between two

teeth.

The absence of a response to percussion is quite possible when there is

chronic periapical inflammation.

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f a metallic instrument is used, the sound produced by percussing a

tooth with periapical disease is sometimes obviously duller than that given by

a tooth with an intact periape#.

$. %alpation" in this simple test, light pressure is applied with the fingertip, to

e#amine tissue consistency and pain response.

Although simple, it is an important test

ts value lies in locating the swelling over aninvolved tooth and determining the following"

i. whether the tissue is fluctuant and enlarged

sufficiently for incision and drainage.

ii. the presence, intensity and location of pain

iii. the presence and location of adenopathy

iv. the presence of bone crepitus.

hen palpation is used to determine adenopathy, it is advisable to

e#ercise caution when palpating the lymph nodes, in the presence of an acute

infection, to avoid the possible spread of infection through the lymphatic

vessels.

Dianostically!

hen posterior teeth are infected, the subma#illary lymph modes

become involved.

hen anterior teeth are involved, the submental lymph nodes become

involved.

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Tenderness over the root ape# of a tooth indicates inflammation of the

periodontal membrane. /ut this can also result from other causes other than

pulpal diseases.

)#cluding absess formation associated with periodontal disease,

swelling of the mucosa over the root ape# of a tooth denotes partial or

complete necrosis of the pulp.

hen the infection is confined to the pulp and has not progressed into

the periodontium, palpation is not diagnostic.

0alpation, percussion, mobility and depressibility test the integrity of

the attachment apparatus i.e. the periodontal ligament and bone, and are

not diagnostic when the disease is confined within the pulpcavity of a

tooth.

n short, palpation, mobility and depressibility are tests of the

periodontium rather than of the pulp.

+* #obility , Depressibility testin"

The mobility test is used evaluate the integrity of the attachment

apparatus surrounding the tooth.

The test consists of moving a tooth laterally in its sockets by using the

fingers or preferably, the handles of two instruments.

The ob!ective of this is to determine whether the tooth is firmly loosely

attached to its alveolus.

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The amount of movement is indicative of the condition of the

periodontium. The greater the movement, the poorer the periodontal

status.

Similarly, the test depressibility consists of moving a tooth vertically in

its socket.

This test may be done with the fingers or with an instrument.

hen depressibility e#ists, the chance of retaining the tooth rangesfrom poor to hopeless.

Classification of mobility" *According to 5rossman+

i+ ;irst degree mobility" is barely discernible movement.

ii+ Second degree mobility" is a hori>ontal movement of ' mm or less.

iii+ Third degree" is a hori>ontal movement of greater than 'mm, often

accompanied by a vertical component of mobility. The pressure

e#erted by the purulent e#udates of an acute apical abcess may

cause some mobility of a tooth. n this situation the tooth may

quickly stabili>e after drainage is established and occlusion is

adusted.

&dditional causes for tooth mobility"

'. Advanced periodontal disease.

-. &ori>ontal root fracture in the middle and coronal third.

1. Chronic bru#ism clenching.

Note on #obilometers!

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These are electronic devices gadgets which aid in determining

tooth mobility.

The apparatus essentially consists of two electrodes or prongs which

hold the facial and lingual surface of the teeth. The degree of mobility tested is

then reflected as a numerical reading either on the instrument itself or on an

attached computer screen.

Radiorap"s!

The radiograph is one of the most important clinical tools in making

a diagnosis.

/ut some clinicians rely e#clusively on radiographs to arrive at a

diagnosis which can lead to ma!or errors in diagnosis and treatment.

/ecause the radiograph is a two dimensional image of a 17dimensional

ob!ect, misinterpretation is a constant risk.

To use radiographs properly, the clinician must have the knowledge and

skill necessary to interpret them correctly.

A thorough understanding is required of the underlying normal or

anomalous anatomy and the changes that can occur due to aging

trauma, disease and healing.

t is important that radiographs be of e#cellent quality.

To produce an e#cellent radiograph one must master the necessary

skills"

'. 0roper placement of the film in the patientFs mouth.

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-. Correct angulation of the cone in relation to the film and oral structures

*to prevent distortion of the anatomic images+.

1. Correct e#posure time 6 so the images are recorded with identifiable

contrasts.

=. 0roper developing technique.

Radiorap"s can contain information on!

'. 0resence of caries that may involve or may threaten to involve the pulp.

-. The number course, shape, length and width of the root canals.

1. the presence of calcified material in the pulp chamber or root canal.

=. the resorption of dentin originating within the root canal internal

resorption or from the root surface *e#ternal resorption+.

?. Calcification or obliteration of the pulp cavity.

@. Thickening of the periodontal ligament.

. 9esorption of cementum.

B. 2ature and )#tent of periapical and alveolar bone destruction.

. 9oot ;racture.

hen posterior teeth are being investigated, a bite wing film provides

an e#cellent supplement for finding the e#tent of carious destuction, the depths

of restoration, the presence of pulp caps or pulpotomies and dens evaginatus or

invaginatus.

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Root fractures" These could be difficult to detect on a radio graph, especially

vertical root fractures which can be identified only in advanced cases of root

resorption.

&ori>ontal fractures maybe confused radiographically with linear

patterns of bone trabecule.

The two can be differentiated by noting that the lines of bone trabeculae

e#tend beyond the border of the root while root fractures often cause

thickening of the periodontal ligament.

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Difference bet-een internal and e.ternal resorption!

(ifferentiation between internal and e#ternal resorption maybe made

radiographically"

'. The lesion of internal resorption usually has sharp smooth margins that

can be clearly defined. &owever, it need not be symmetrical.

-. The pulp disappears8 into the lesion not e#tending through *i.e. the

shadow of the pulp+ the lesion in its regular shape.

Radiorap"ic misinterpretation!

n some instances two or more e#posures are necessary to check out

detail from more than one hori>ontal angle. This is especially in the case of the

mental foramen 6 this foramen maybe directly superimposed over the ape# of

the mandibular premolars for e#ample.

The nasopalatine foramen also maybe superimposed on the ape# of the

ma#illary central incisors.

These foramina are actually some distance from the apices of these

teeth.

To find out whether it is a foramen or truly a periapical lesion one must

change the hori>ontal angle of the cone of the #7ray machine to the

mesial distal during separate e#posures.

f the radiolucent arc is actually a lesion associated with the periape#

than its shadow will remain attached8 to the root end despite of a

mesial or distal shift in separate films.

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%esions -it"in t"e toot" obser'able by radiorap"s!

a. 0ulp death in a developing tooth is readily apparent because the

root ceases to develop.

b. 0ulp stones, inflammation.

c. nternal resorption seen following traumatic in!ury.

%esions outside t"e toot" obser'able on radiorap"s!

Some of the most common occurrences seen radiographically on the out

side of the root of the tooth are 6

a. idening of periodontal space occurring due to

Acute apical periodontitis.

Acute apical abscess

$cclusal trauma.

b. Changes associated with chronic periapical abscess.

c. )#ternal root resorption.

n case of e#ternal root resorption" lesion has ragged margins and

shadow of the pulp passes through8 the lesion unaltered.

RADIOGRAP$ ANGU%AR , PERIRADICU%AR %ESIONS

#ost often t"e follo-in features are seen!

idened periodontal ligament space

nflammatory apical root resorption

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%ost often associated with pulp necrosis and

infection.

Ot"er conditions -"ere one can notice a -indened PD% space are!

Acute apical periodontitis

A beginning acute apical abscess

Acute pulpitis *occasionally+

Radiorap"ic c"anes as se/uelae to pulp necrosis

T"e commonly obser'ed c"anes are!

a+ Chronic apical periodontitis 6 a well circumscribed osseous lesion

9adiolucent area varying in si>e from a few mms to a cm or

larger in si>e

/order bony perimeter maybe radiopaque.

(o not always occurs at the periape# occasionally seen on the

lateral surface of the root in association with an accessory canal.

b+ Chronic apical abscess"

4arger, more diffuse and irregular radiolucent

lesion.

c+ Apical cyst" may develop from a chronic abscess.

n this case lesion appears 6 more circumscribed, more like a

granuloma8 in appearance.

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t also moves roots of teeth laterally.

NAT0INhas postulated that the larger the lesion the more apt it is to be a

cyst.

A number of pathologic changes in and near the alveolar process maybe

mistaken for periradicular lesions of pulpal origin. They are"

I. Lesions of non endodontic origin:

'. 5lobuloma#illary cyst 6 inverted pear shaped.

-. %idline palatal cyst 6 occurs in the midline.

1. Cyst of the nasopalatine canal or foramen 6 occurs mainly in the

palatine process.

II. Periodontal lesions" maybe mistaken for periradicular ones.

The periodontal probe and pulp tester are invaluable in

determining the origin of the lesion.

Another method is to place a silver or gutta percha point in the

periodontal pocket and take a radiograph.

III.Cementoblastoma" common errors in diagnosis center around the lesions

of cementoblastoma particularly during stage when radiolucency is so

apparent.

*$nce it begins to calcify into a selerotic lesion, little doubt should e#ist

about the nature of the lesion+.

1* T"emal testin!

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$ne of the most common symptoms associated with a symptomatic

inflammed pulp is pain induced by hot or cold stimulation.

&ot and cold tests are valuable diagnostic aids.

According to 5rossman, although both are tests of sensitivity they are

dissimilar and are conducted for different diagnostic reasons.

A response to cold indicates a vital pulp, regardless of whether that pulp is

normal and abnormal.

A heat test is not a test of pulp vitality. An abnormal response to heat

usually indicates the presence of a pulpal or periapical disorder requiring

endodontic treatment.

Another diagnostic difference pointed out by 5rossman is that

when a reaction to cold occurs the patient can quickly point out

to the painful tooth.

hereas in a heat test, the response could be locali>ed or

diffused or even referred to a different site.

The results of the thermal test should be correlated with the results of

other tests to ensure validity.

Tec"ni/ue of performin t"ermal tests!

/efore testing, the patient should be told what tests are going to be

performed and why.

Additionally, the patient should be given some idea of what to e#pect.

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The tests should be first performed on teeth which are to be used as

controls i.e. corresponding *if found+ on the opposite side of the same

arch. Contralateral teeth can also be used as controls.

/y doing so, the patient gets an idea of how the tests will feel.

The dentist should also inform the patient how to respond when a

sensation is e#perienced.

For Eg" The patient should be instructed to raise a hand as soon as anysensation is felt.

The heat or cold test (een EPT! tests are performed b" placing the stimuli on:

&nterior teeth" labial *enamel+ surface of the incisal third of the crown.

%osterior teeth" $ccluso /uccal surface.

&owever, placing the stimulus on e#posed dentin should be avoided 6

because an accelerated or e#agerrated response is likely.

Also the stimulus should not be applied against restorations unless

unavailable.

2on7metallic restorations" 0oor conductors

tests gives a delayed response or no response

'etallic(restorations" 5ood conductors

This can result in response at low levels of stimulation.

They may also cause misleading results by conducting the

stimulus to an ad!oining metallic restoration in another tooth.

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This effect can be reduced by placing a celluloid strip between the

teeth.

The teeth in the quadrant must first be isolated and then dried with -#-

inch gua>e and a saliva e!ector placed.

Cohen states that teeth should not be dried with a blast of air because

9oom temperature air might cause shock.

Saliva might be sprayed on the clinician or the assistant.

!eat Test" The heat test can be performed using different technique that

deliver different degrees of temperature.

According to Cohen the preferred temperature is

@?.?HC *'?DH;+. /ut according to A&9 9owe et al in his article on

Assessment of pulpal vitality *nt )nd 3ournal 'D :7-1+ temperatures

upto '?DHC are necessary for conducting thermal tests on teeth which are

first smeared with :aseline to avoid g.p. sticking to tooth.

#eat testing can be made with

&ot air blast

&ot water

&ot burnisher any instrument which can deliver

controlled temperature to the tooth

&ot 5utta7percha

here a gold crown is present, heat maybe applied by polishing the

crown with an Abrasive disc.

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hen testing with gutta7percha, it is heated over an alcohol flame until

it becomes shiny and sags, but before it begins to smoke.

Care should be taken not to place an overheated gutta percha stick or

prolonged application of the stick as it may cause a burn lesion in an otherwise

normal pulp.

A different technique is required for the application of hot water.

$ethod" solate with rubber dam

Tooth is immersed in Coffee hot8 water delivered from a

syringe.

*According to Cohen this is the best method for thermal testing teeth

with porcelain or full metal coverage+.

)isadvanta*es" The response noted is limited to only the tooth which is tested.

old Test" ;or the cold testing, the teeth must remain isolated and dry.

The most common techniques for cold testing utili>e,

'. A stream of cold air from a 1 way syringe directed against the crown of

a previously dried tooth.

-. )thyl chloride spray 6 it is sprayed liberally on a *evaporates rapidly by

absorbing heat and cooling the tooth surface+ cotton pellet and held

against the middle 1rdof the facial surface.

The ethyle chloride technique is effective even on teeth covered with

cast metal crowns.

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1. Sticks of ice

=. Carbon dio#ide snow in the form of dry ice pencil.

This produces lower intrapulpal temperatures than other methods

*Aisberger and 0eters 'B'+.

s far more effective *)hrmann, '1+.

9eliable even in immature teeth.

Responses to t"ermal tests!

The patients responses to heat and cold testing are identical because the

neural fibres in the pulp transmit only the sensation of pain *&ydrodynamic

theory 6 /rannstorm+.

There are four possible reactions the patient may have"

'. 2o response 6 pulp maybe non vital

$r vital, but giving a false negative response because of

)#cessive calcification

mmature ape#

9ecent trauma

0atient premedication

-. A mild to moderate transient thermal pain response.

This is usually considered normal.

1. A strong, painful response that subsides quickly after removal of the

stimulus 6 this is characteristic of 9eversible pulpitis.

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t does not provide any information about

the vascular supply to the tooth, which is the real determinant of

vitality.

Techni#ue"

'. (escribe the test to the patient in a way that will reduce an#iety and

will eliminate a biased response. To eliminate a biased decision )0T

should first be performed on a normal healthy tooth *control+, ad!acent

or contra lateral. This aids in determining the patients threshold level.

-. solate the area of teeth to be tested with cotton rolls and a saliva e!ector

and air dry all the teeth.

1. Check the electric pulp tester for function, and determine that current is

passing through the electrode.

=. Apply an electrolyte *tooth paste+ on the tooth electrode and place it

against the dried enamel of the crownsF occlusobuccal or inciso labial

surface.

All restorations must be avoided because they may

cause a false reading.

?. 9etract the patients cheek away from the tooth electrode with the free

hand. This hand contact with the patients cheek completes the electrical

circuit.

@. Turn the 9heostat slowly to introduce minimal current into the tooth

and increase the current slowly.

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0atients should be instructed to raise a hand as

soon as they begin to feel slight tingling or sensation of heat.

9ecord the result according to the numeric scale on

the pulp tester.

)ach tooth should be tested - or 1 times and the reading averaged.

Reason" The patientFs response may vary slightly *which is common+ or

significantly *which suggests a false positive or negative the response+.

3actors 4 affectin le'el of Response!

'. )namel thickness" Thicker the enamel, the more delayed the response.

*Thin anterior teeth 6 respond faster, /road posterior teeth 6 slower

response 6 because of greater thickness of enamel and dentin+.

-. 0robe placement on the tooth.

*0osterior teeth" occlusal third, anterior teeth" ncisal third 6 to avoid

false stimulation of gingival tissue+.

1. (entin calcification

=. nterfering restorative materials.

?. The cross sectional area of the probe tip

@. patient level of an#iety.

Ad'antaes of E*P*T!

'. ntensity of stimulus is comfortable to the patients.

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-. The digital display of many ).0. Testors provides instant, easy and

reliable information.

1. n some ).0. testers, a red indicator light flashes on and off when

ma#imum stimulus is reached.

=. 5ives a quantitative reading which can be compared with the normal

reading of control tooth.

Disad'antaes of EPT!

'. t cannot be used on patients having cardiac pacemaker because of

potential interference with the pacemaker.

Studies by woolley and associated have shown that currents of the

magnitude of ? to -D milliamps are sufficient to modify normal pacemaker

function.

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fibres entering the tooth offers a possible e#planation to why electric pulp tests

tend to be unrealiable in young teeth.

?. 9ecently traumati>ed teeth cannot be tested.

@. The probe tip of some )0T is removable and it falls out easily.

. 2o indication is given regarding the state of vascular supply which

would give a more reliable measure of the vitality of the pulp.

B. 9eadings from posterior teeth with partial vital pulps maybe

misleading. *because in multirooted teeth one canal may have vital pulp

tissue and other canals necrotic tissue+.

+alse Readin*" As stated, the results from the )0T could be misleading and

these could be grouped as"

A+ ;alse positive response" means the pulp is necrotic but the patient

nevertheless signals that he feels sensation.

/+ ;alse negative response" means the pulp is vital but the patient appears

unresponsive to electric pulp tests.

#ain reasons for a false positi'e response!

'. Conductor )lectrode contact with a larger metal restoration *bridge,

class restoration+ or the gingiva allowing the current to reach the

attachment apparatus.

-. 0atient an#iety.

1. 4iquifaction necrosis may conduct current to the attachment apparatus

and the patient may slowly raise hishand near the highest range.

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'. Analytic technology pulp tester" &ere the wave form has an output in

the form of bursts of ten high frequency pulses followed by a space.

This is done to minimi>e patient discomfort.

The )0T is turned on automatically when the probe touches the

tooth and is turned off when the tooth contact is broken *after a

delay of '? secs+.

There is a digital display and the only control on the )0T is therate of increase of the stimulus.

To complete circuit patient may touch metal handle.

-. (igilog pulp tester

1. 5reen wood pulp tester

=. 0elton crane pulp tester

?. 0arkell pulp tester *battery operated+

Periodontal E.amination!

2o dental e#amination is complete without careful evaluation of the

teethFs periodontal support.

The periodontal probe should be an integral part of all

endodontic tray set ups.


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%ultirooted teeth are carefully probed to determine whether

there is any furcation involvement.

A lateral canal e#posed to the oral cavity by periodontal

disease may become the portal of entry for to#ins that cause pulpal

degeneration.

To distinguish lesion of periodontal origin from those of

pulpal origin, thermal and electric pulp tests, along with periodontal

e#amination are essential.

5* Test Ca'ity!

This method is performed when other diagnostic methods have failed.

t involves the slow removal of enamel and dentin to determine pulp

vitality.

ithout anesthesia and using a small round bur, the dentist removes the

dentin with a revolving high speed bur aimed directly at the pulp.

f the pulp is vital, the patient will e#perience a quick sharp, pain at or

shortly beyond the dentin enamel !unction.

A sedative cement can then be placed in the prepared cavity and the

search for the cause of pain may be continued.

$n the contrary, if no pain sensitivity is recorded, the cavity

preparation maybe continued until the pulp chamber is reached and if

the pulp is noticed to be necrotic, routine endodontic treatment could be

performed.

1=


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67* Anest"esia test!

n the uncommon circumstance of diffuse strong pain of vague origin,

when all other tests have failed, the Anesthesia test is performed.

$b!ective" To anestheti>e a single tooth at a time until the pain

disappears and is locali>ed to a specefic tooth.

Techni#ue" ed, anestheti>e,

the ne#t tooth mesial to it and continue to do so until the pain

disappears.

f the source of pain cannot be determined whether in ma#illary or

mandibular teeth, an inferior alveolar *mandibular block+ infection

should be given.

Cessation of pain naturally indicates involvement of a mandibular

tooth, and locali>ation of the specefic tooth is done by the intraligament

in!ection, when the anesthetic has spent itself.

This test is obviously a last resort and has an advantage over the Test

cavity8, during which iatrogenic damage is possible.

66*,cclusal pressure or -itin* test" A frequent patient complaint is pain on

biting or chewing.

auses for such symptoms" 7 Apical periodontitis,

7 Apical abscess

1?


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;iberoptic lighting and chairside magnification have become

indispensable in the search for cracks, fractures and unfound canals and

obstructions in root canal therapy.

The fact that magnification *e.g. microscopes+ and trasillumination

might allow the dentist the only means of diagnosing an offending

cracked tooth is becoming an increasing reality.

6:*Stainin*" The purpose of a staining test is isolation of a cracked tooth.

Techni#ue" there are 1 methods to stain a tooth.

'. 9emove the filling from the suspected tooth and place -J odine in the

cavity preparation. The iodine stains the fracture line fracture lines can

be identified with food colouring placed on the dried occlusal surface.

The dye solution stains the fracture line.

The occlusal surface is cleaned with a cotton pellet lightly

moistened with DJ isopropyl alcohol.

The alcohol washes away the food coloring on the surface, but

the colouring within the fracture line remains and becomes apparent

-. %i# a dye in >inc o#ide eugenol cement and place it in the cavity

preparation after filling has been removed. The dye will seep out and

line the fracture.

1. &ave patient chew a disclosing tablet after taking out the filling of the

fractured tooth. The fracture line will be stained.

SPECIA% #ET$ODS

1


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6* ;eroradiorap"y!

Eeroradiography is an imaging technique that has been proposed as an

alternative to conventional #7ray film radiography. The term #ero7radiography

is derived from the greek word #eros8 which means dry8.

Techni#ue" The #7ray image is recorded on a photo7conductive selenium

coated plate rather than #7ray film.

/efore use, the selenium plate is given a uniform electrostatic charge,

placed in a light proof plastic cassette, positioned in the mouth, e#posed to #7

ray.

The processed image is transferred onto clear adhesive tape and fi#ed

on to an opaque plastic base.

The resulting image maybe viewed either as a photograph with

reflected light or as a radiograph with transmitted light from a view

bo#.

Ad'antaes!

'. The radiation e#posure is '1rdthat of the conventional #7ray film.

-. /etter edge enhancement and image quality.

1. Eeroradiographs have inherently wide latitude.

i.e. it is possible to image ob!ects having a broad range of densities in a

single e#posure.

ide latitude also means the acceptable images can be obtained

over a relatively broad range e#posure conditions.

1B


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8* Pulse O.imetry!

Tests relying on the passage of light through a tooth have been

considered as a possible means of detecting pulp vitality with greater

ob!ectivity.

The pulse o#imeter is a non7invasive $- saturation monitor that

provides continuous pulse rate readings.

The liquid crystal display *4C(+ gives o#ygen saturation, pulse rate

and plethysmpographic wave form readings.

oncept" 0ulse o#imetry uses red and infrared wave length in order to

transilluminate a tissue bed and detects absorbance peaks due to pulsative

circulation.

This information is used to calculate the pulse rate and o#ygen

saturation.

The tooth to be tested is sandwiched between a photoelectric detector

and red and infrared light emitting diodes.

This method is clearly superior to other vitality tests since it does not

rely upon sensory nerve response. *$ther routine methods rely on stimulation

of a7delta nerve fibres for assessment of pulp vitality+.

=D


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)* %aser Doppler 3lo-metry!

(ue to the biased, false 6ve and positive responses elicited through the

)0T the need for a better and more reliable method for determining pulp

vitality arose.

A method which determined and registered the blood flow rather than

the neural response was preferred.

4(; was thus introduced first in '- to determine blood flow in9etina of 9abbits 6 9:A, 9oss and /enedek as a non7invasine method to

measure blood flow.

The cru# of the 4(; is based on the detection of movement of blood

cells in the pulpal blood vessels, with thus gives a true picture regarding

pulp vitality.

Techni#ue" essentially consists of a laser light i.e., helium neon laser at

@1-.Bnm.

t is focused on the tissue under study with a fiber optic probe.

As the light hits the various components of the tissues, it is partially

absorbed and partially back scattered.

The bac& scattered light has ' components:

i+ 4ight back7scattered from the static tissues which

has the same frequency as the light going on.

ii+ The other component is the (oppler shifted light

with a different frequency.

='


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t is possible to determine the bucco7lingual and mesio7distal widths of

teeth and the presence or absence of root canal filling materials and

metal posts.

Also observable are the carious lesions, e#tension of the ma#illary sinus

and its pro#imity to the root apices.

Ad'antaes!

'. $bservation of structures which are difficult to visuali>e with

conventional #7rays.

-. 0rovides images for 17dimensional image of roots, root canals and

teeth.

Disad'antaes!

'. )#pensive

-. Skin dose is large

1. Time consuming.

+* Diital subtraction radiorap"y!

The progress of caries from an incipient lesion, the ()3 is often

difficult to detect.

4ikewise, the assessment of healing or e#pansion of the periapical

lesion after root canal therapy is a challenge therefore the subtle

changes in the density of the lesions maynot be detectable with the

naked eye.

Subtraction radiography offers a remedy for these problems.

=1


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t is an image enhancement method. &ere, the area under focus is

clearly displayed against a neutral gray black background or it is

superimposed on the radiograph itself *i.e. the required areas are

enlarged against the entire background+.

This (S9 maybe used to assess the successfulness of 9CT and also

periapical lesions.


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/ut, the resolution of 9:5 is slightly lower than that produced with

conventional film, which can however be improved through enhancement

procedures.

1* Computeri&ed e.pert system!

9eported by 3ohn ;irrola, the C)S :i>, Comende# was used for the

diagnosis of selected pulpal pathosis i.e.

2ormal pulp

9eversible pulpitis.

rreversible pulpitis *due to hyperocclusion+.

2ecrotic pulp

nfection due to endodontic failure.

Appropriate diagnostic case facts are obtained and this data is entered

into the computer. The computer checks and gives out the diagnosis.

7 ith rapid advances being made in the field of

computers one can e#pect more efficient programmes for endodontic

diagnosis.

Conclusion!

To conclude, would like to say that one cannot depend solely on these

tests to arrive at a diagnosis.

7 As mentioned before, the clinicians knowledge,

skill and art combined with these diagnostic tests will help one to make the

right diagnosis.

=?


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Documents

Diagnostic Procedures / orthodontic courses by Indian dental academy