Endodontic DIAGNOSTIC METHODS

Endodontic diagnostic aids 219
ENDODONTIC DIAGNOSTIC AIDS

CONTENTS
1) Introduction
2) History
i. Medical
ii. Dental
3) Examination & Diagnostic Tests
i. Usual and Tactile inspection
ii. Palpation
iii. Percussion
iv. Mobility and depressibility
v. Radiographs
vi. Thermal test
vii. Electric pulp test
viii. Anesthesia test
ix. Test cavity
x. Occlusal pressure test
xi. Transillumination
4) Advanced Diagnostic Tests
i. Pulp Hemogram
ii. Photo plethysmography
iii. Pulse oximetry
iv. Laser Doppler flowmetry
v. Dual Wavelength Spectrometry
vi. Computerized Tomography
vii. MRI- Magnetic Resonance Imaging
viii. Computerized Expert System
ix. TACT (Tuned Aperture Computed Tomography)
x. Hughes Probeeye Camera
xi. Liquid Crystal Testing
xii. CITI (Computerized Infra-RedThermographic Imaging)
5) Summary
6) References
Introduction
Diagnosis as defined by dictionary is art of identifying disease from
its signs / symptoms. Although scientific devices can be used to gather some
information, diagnosis is primarily an art because it is the thoughtful
interpretation of the data that leads to a diagnosis.
Correct treatment begins with a correct diagnosis. An accurate
diagnosis is a result of the synthesis of scientific knowledge, clinical
experience, intuition, and common sense.
Symptoms are the units of information sought in clinical diagnosis.
Symptoms are defined as phenomenon or signs of a departure from the
normal and are indicative of illness.
Symptoms can be:
1) Subjective Symptoms - experienced and reported to the clinician by the
patient.
2) Objective Symptoms – those ascertained by the clinician through various
tests.
Many diseases have similar symptoms, thus the clinician must
differentiate one from another.
Differential Diagnosis - This technique distinguishes one disease
from several other similar disorders by identifying their differences.
Thus the criteria for an accurate clinical diagnosis includes :
- A good case history
- A thorough clinical examination
- Relevant investigations / diagnostic tests.
HISTORY
Medical
Even though there are virtually no systemic contraindications to
endodontic therapy [except uncontrolled diabetes or very recent myocardial
infection] a recent and comprehensive medical history is mandatory.
It is only with such a history that the clinician can determine whether
medical consultation or premedication is required before diagnostic
examination or clinical treatment is undertaken.
Some patients may require antibiotic prophylaxis before commencing
the treatment because of systemic conditions like :
- Heart valve replacement
- History of rheumatic fever
- Advanced Aids
In case of patients is on anticoagulant medications, either the dose
may have to be reduced or suspended esp. for periodontal examination.
Additionally, the clinician should be aware if the patient has drug
allergies or allergies to dental products, an artificial joint prosthesis, or organ
transplants or is taking medications that may negatively interact with
common local anesthetics, analgesics, and antibiotics. Several medical
conditions have oral manifestations, which must be carefully considered
when attempting to arrive at an accurate dental diagnosis. Many of the oral
soft tissue changes that occur are more related to the medications used to
treat the medical condition than the medical condition itself.
Patient who present with mental or emotional disorders are not
uncommon. In these cases too medical consultation before the diagnostic
examination would be in the best interest of patient, doctor and staff.
Dental History:
A record of the chief complaint, the signs and symptoms the patient
reports, when the problem began and what the patient can discuss that
improves / worsens the conditions is created.
The most effective way for the clinician to gather this important
information is to ask the patient relevant questions regarding the chief
compliant and listen carefully and sensitively to the patient responses.
Whatever the reason patient’s chief complaint is the best starting

point for a correct diagnosis. The most common complaint that leads to
dental treatment is PAIN – which is a “subjective symptom”. Judicious
questioning about the pain can aid the diagnostician in developing a
tentative diagnosis quickly.
History of pain:
One should ask the patient about:
- Kind of pain
- Its location
- Its duration
- What alleviates pain
- Referred to another site or not.
Type / Kind of pain
Generally patients describe pulpal pain in one of two ways.
a. Sharp Piercing and lacinating – such a pain is associated with
excitation of “A-Delta” nerve fibres. Pain reflects on reversible state
of pulpitis.
b. Dull, boring growing or excruciating – associated with excition and
slower rate of transmission of the “C” nerve fibres in the pulp. Pain
reflects on irreversible state of pulpitis.
Localisation of pain
The ability to localise the pain is obviously important
 Pain is localise when the patient can point to a specific tooth or site
with assurance and speed.
 Usually sharp, piercing lancinating pain in a tooth is easy to localise
and responds promptly to cold.
 When pain is diffuse patient describe area of discomfort which is due
to dull, boring , gnawing pain and tooth responds abnormally to heat
more than to cold.
Duration of pain
The duration of pain is also diagnostic
 Sometimes pulpal pain lasts only as long as an irritant is present.
 At other time it may last for a longer period even after removal of the
irritant
Referred pain
At times pain is referred to other areas and even beyond the mouth.
Most commonly it is manifested in other teeth in the same or the opposing
quadrant.
However, referred pain is not necessarily limited to the other teeth. It
may e.g. be ipsilaterally referred to the pre-auricular area or down the neck
or the temporal area. In these instances source of extraorally referred pain
almost invariably is a posterior teeth.
Patients may report that their dental pain is exacerbated with change
in position.
This occurs because of the increase in blood pressure to the head
which increases the pressure on the confined pulp, as pulp is:
i. encase in hard tissue i.e. dentin
ii. no collateral supply
Differential diagnosis
Acute reversible pulpitis Irreversible pulpitis
Nature Pain sharp lancinating perircing Dull, boring, gnawing

excruciating pain
Duration Short duration disappears after Longer duration persists even

removal of the stimulus after removal of stimulus
Response to Responds to cold Responds abnormally to

cold/heat heat then to cold
Localization Usually localized Diffuse

Pediatric considerations
History of either presence or absence of pain may not be as reliable in
the differential diagnosis of the condition of exposed pulp in primary tooth
as it is in permanent tooth. Degeneration of primary pulp even to the point of
abscess formation can occur without the child’s recalling pain & discomfort
is not uncommon.
Examination & Testing
Basic diagnostic protocol suggests that a practitioner observe patients
as they enter the operatory. Signs of physical limitations may be present, as
well as signs of facial asymmetry that result from facial swelling. Visual and
palpation examinations of the face and neck are warranted to determine if
swelling is present. Many times a facial swelling can be determined only by
palpation when a unilateral “lump or bump” is present. The presence of
bilateral swellings may be indicative of a normal finding for any given
patient; however, it may also be a sign of a systemic disease. Palpation
allows the practitioner to determine if the swelling is localized or diffuse,
firm or fluctuant. These latter findings will play a significant role in
determining the appropriate treatment.
Objective symptoms are examined by the tests and observations
performed by the clinician. These tests are :
Commonly used diagnostic tests
1. Usual and Tactile inspection
2. Palpation
3. Percussion
4. Mobility and depressibility
5. Radiographs
6. Thermal test
7. Electric pulp test
8. Anesthesia test
9. Test cavity
10. Occlusal pressure test

11. Transillumination
Advanced Diagnostic Tests
1. Pulp Hemogram
2. Photo plethysmography
3. Pulse oximetry
4. Laser Doppler flowmetry
5. Dual Wavelength Spectrometry
6. Computerized Tomography
7. MRI- Magnetic Resonance Imaging
8. Computerized Expert System
9. TACT (Tuned Aperture Computed Tomography)
10. Hughes Probeeye Camera
11. Liquid Crystal Testing
12. CITI (Computerized Infra-RedThermographic Imaging)
Visual and tactile inspection
 This is one of the simplest clinical tests.
 Mostly the clinician performs this test tool
casually as a result much essential information is lost.
 A thorough visual, tactile examination of hard and
soft tissues relies on three “Cs – i.e contour, Colour and consistency”.
In soft tissues e.g. GINGIVA
Colour – Deviation from healthy pink colour to red colour is seen as in
inflammation.
Contour – Swelling causes change in contour
Consistency – In pathologic conditions gingival becomes soft, spongy and
fluctuant.
In hard tissue i.e. TEETH

Colour – Normal appearing crown has a life like translucency and sparkle,
where as teeth with necrotic pulp may appear discoloured, opaque
and less life like.
The discolouration can be caused by (apart from necrotic pulp)
i) Old amalgam restorations
ii) Root canal filling materials and medicaments
iii) Systemic medicaition such as tetracycline
Contour
Change in crown contour can occur due to:
- Fractures
- Wear facets
- Restorations
- Abrasion
- Erosion
- Attrition
- Developmental defects
 Clinician should be prepared to evaluate the possible effects of such
changes on the pulp.
Consistency: of hard tissues relate to the presence of caries and internal or
external resorption.
Technique: This simple technique can be performed with finger, an
explorer and periodontal probe.
The test should be carried out in good light under dry condition. This is
because:
(i) If covered by saliva clinician may not be able to detect the presence
of a sinus tract
(ii) Same way if packed with food interproximal cavity may escape
notice
(iii) Loss of translucency, slight colour changes, cracks may not be

visible in poor light.
- Visual examination should also be used routinely to determine the
periodontal status of the suspected tooth and adjacent teeth.
- The crown of the tooth should be carefully evaluated to determine
whether it can be restored properly after completion of endodontic
treatment.
Palpation
- This simple test uses light pressure with the fingertip to examine
tissue consistency and pain response.
- Although simple, it is an important test.
- Main features of the test are:
i) Helps in location of swelling over an involved tooth
ii) Whether the tissue is fluctuant and enlarged sufficiently for
incision and drainage.
iii) The presence, intensity and location of pain
iv) The presence and location of adenopathy i.e. Palpation of
lymph nodes
v) The presence of bone crepitus.
Note: During palpation of lymph nodes in the presence of an acute infection
care must be assured to avoid the possible spread of infection through the
lymphatic vessels.
- Diagnostically when posterior teeth are infected the submaxillary
lymph nodes are involved and in lower anterior teeth infection
submental lymph nodes are involved.
- When the infection is confined to the pulp and has not progressed into
the periodontium palpation is not diagnostic.
- Excluding abscess formation associated with a periodontal disease,

swelling of the mucosa over the root apex of a tooth denotes partial or
complete necrosis of pulp.
Percussion
- This test enables one to evaluate the status of the periodontium
surrounding a tooth.
- This test can be done using the finger or with the handle of an
instrument.
- A painful response to percussion signifies inflammation of the
periodontal membrane (Periodontitis).
- In performing this test, several teeth are percursed in a random order,
to eliminate bias on part of the patient.
- The direction of the blow should be changed from vertical-occlusal to
the buccal or lingual surface of the crown and strike separate cusps in
a differing order.
- Percussion of tooth should be done very gently (not beyond patients
tolerance) and if no response, sharp tap is given.
- Percussion may be misleading if used alone, thus used in conjunction
with other periodontal tests such as palpation, mobility and
depressibility.
- A tender tooth does not always denote a pulpal involvement (i.e. Pulp
necrosis).
- Apart from pulpitis, tooth may be tender in acute periodontal abscess.
Acute apical peridontitis may also result from traumatic occlusion or
sinusitis, though the pulp is vital.
- Absence of a response to percussion may be seen in chronic
periapical inflammation.
- A dull not signifies abscess formation and a sharp note merely
inflammation.
Mobility – Depressibility testing:

- This test is used to evaluate the integrity of the attachment apparatus
surrounding the tooth. The objective is to determine whether the tooth
is firmly or loosely attached to its alveolus. Greater the movement,
poorer is the periodontal status.
- Alternating lateral forces in a facial-lingual direction is applied to
observe the degree of mobility of the tooth within the alveolus ..
- Mobility is detected by using
i. Finger.
ii. Handles of two instruments.
iii. Mobilometers.
Classification of mobility (According to Cohen and Grossman)
Ist Degree – Barely discernible movement
IInd Degree – Horizontal movement of 1mm or less.
IIIrd Degree – Horizontal movement of greater than 1 mm often
accompanied by vertical movement.
Horizontal root fracture in the coronal or middle third and chronic
bruxism also cause tooth movement apart from periodontal disease.
Mobilometers: (Periodontometer) – By Muhlemann in 1954.
- standardized method for measuring even minor tooth displacements.
- a small force is applied to the crown of a tooth. The crown starts to
tip in the direction of the force..
Disadvantage :
- Its application was limited to the anterior teeth.
- Not practically useful for large surveys as the instrument is attached
in dental unit. Depressibility
- The test for depressibility consists of moving a tooth vertically in its
socket.
- Performed with fingers or with an instruments when depressibility

exists, the chance of retaining the tooth ranges from poor to hopeless.
Pediatric considerations:
- Mobility in primary tooth may result from physiological or
pathological cause.
- Thus pathological mobility must be distinguished from normal
mobility in primary teeth near exfoliation.
Radiographs:
- Radiograph is one of the most important clinical tool in making a
diagnosis.
- But some clinician rely solely on radiographs to arrive at a diagnosis
which can lead to major errors in diagnosis and treatment. As the
radiograph is a two dimensional image of a three dimensional object
misinterpretation is a constant risk.
- To use radiographs properly, the clinician must have the knowledge
and skill necessary to interpret them, thorough understanding of the
underlying normal anatomy and the changes that can occur due to
aging, trauma, disease and healing.
Radiograph provide pertinent information regarding:
i. Presence of caries that may involve or threaten to involve the
pulp.
ii. Root anatomy – Show the number, course, shape, length and
width of the root canals.
iii. Position of succedaneous permanent tooth with respect to primay
tooth.
iv. The presence of calcified material in pulp chamber or root canal.
v. Resorption – Internal / external
vi. Calcification or obliteration of the pulp cavity-pulp-stones
vii. Thickening of the PDL.
viii. Resorption of cementum.

ix. Nature and extent of periapical and alveolar bone destruction.
x. Root fracture.
xi. Anatomical landmarks (normal structures) associated with roots
Radiographic interpretation
- Interpretation of good – quality radiographs must be done in an
orderly and consistent manner.
- The radiographs may reveal early pathologic changes in or around the
tooth.
A. Root anatomy
Radiographs provide essential information relative to
i. Normal and abnormal root formation.
ii. Extra root and root canals.
iii. Curvatures
iv. Invagination and dens in dente
Extra root or root canals
- Extra roots can be more clearly viewed if the horizontally directed
beam is from the mesial aspect.
Canals
i) If “an extra-dark line” is present in the coronal third of
the root running parallel to the instrument, a second canal may be
present. E.g. Mesiobuccal of maxillary molars and distal of lower
molars.
ii) “Slowey” described another diagnostic aid – “the fast
break”. A sudden change in the radiolucency with in a canal signals
the presence of an additional canal e.g. maxillary 1st premolars.
Curvatures
Curvatures on buccal or lingual aspect are difficult to be viewed in
radiographs.
B. Lesion within the tooth.

i. Pulp stones
ii. Pulp calcifications
iii. Internal resorption
iv. Root fractures
(i) Internal resorption should be differentiated from external resorption.
Internal External
1. Has sharp, smooth margins that The margins are rough, vary in density
can be clearly defined. and have a moth-eaten appearance.
2. The pulp “disappears” into the The radiographic outline of the root
lesion – not extending through the canal is often apparent within the
lesion in its regular shape. radiolucent area of resorption.
3. When viewed from different If the defect is external the relationship
angulation, defect in relation to of the defect to canal will shift on
canal will remain constant altering the angulation.
(ii) Root fractures

- Fractures of root are difficult to detect on a radiograph.
- Vertical root fractures can only be diagnosed in advanced cases of
root separation as compared to horizontal fractures which can be
readily identified on a radiograph.
- Horizontal fractures must be differentiated from linear patterns of
bone trabecular.
o Root fracture causes thickening of periodontal ligament while
bone trabecular extend beyond the border of the root.
C. Lesion outside the tooth seen on radiographs
- Radiographs do not show much changes in initial pulp necrosis
because to reveal changes on radiograph, 60% cortical bone of
destruction is necessary.
i. Widening of periodontal space is seen in
- Acute apical periodontitis

- Acute apical abscess
- Advanced pulpitis and root fracture
- Changes associated with chronic periapical abscess.
ii. External root resorption.
iii. Changes associated with chronic periapical abcess.
D. Radiographic changes as a sequelae of pulp necrosis.
i) Chronic apical periodontitis
a. Well-circumscribed osseous lesion
b. Radiolucent area varying in size from few mm to few cms
c. Borders may appear to be radioopaque
ii) Apical cyst
a. Difficult to differentiate from chronic apical periodontitis.
b. More circumscribed with a dense bony perimeter.
c. May move the roots.
- Pre-operative radiographs demonstrates pathological conditions,
positiong of succedaneous permanent tooth. This helps in deciding on
performing pulp therapy for primary tooth.
- Radiographic interpretation is more difficult in children than adults.
- Roots of primary teeth undergoing normal physiological resorbtion
often present misleading picture or one suggestive of pathological
changes.
- Permanent teeth with incompletely formed root ends give
impression of periapical radiolucency.
Thermal Test
- One of the most common symptoms associated with inflamed pulp is
pain induced or relieved by hot or cold stimulation.
- Thus thermal tests are one of the valuable diagnostic aids.
Technique
- Explain the patient about the procedure
- Isolate the teeth
- Check on normal side first and then on the involved teeth.
- Ask the patient to raise a hand as soon as any sensation is felt.
- Remove the stimulus immediately when sensation is felt.
The heat or cold tests are performed by placing the stimuli in:
Anterior teeth – on the incisal 3rd of crown of labial surface
Posterior teeth – occluso buccal surface.
Heat test:
- The heat test can be performed using different techniques that deliver
different degrees of temperature.
- According to Cohen temperature preferred is approximately 65. 5°C.
- Heat test can be carried out using
i) Warm air blast
ii) Hot water
iii) Hot burnisher
iv) Hot gutta-percha – Heat it until it becomes shiny and sags but
before it smokes.
v) Hot compound.
- Precautions: Care must be used in applying these all heat test because
the pulp may be damaged by overheating.
- Remove stimuli as soon as patient feels sensation
- Never place an overheated gutta-percha as it may cause a
“burn lesion” in an otherwise normal pulp.
- Apply Vaseline / cocoa butter to prevent the sticking of gutta-
percha on the tooth.
Application of hot water:- Tooth is isolated under the rubber dam and is
immersed in “Coffee hot” water delivered from a syringe.
Cold test
- For cold testing teeth must remain dry and isolated.
- Most common technique to apply cold are:
o A stream of cold air
o Ethyl chloride spray.
o Sticks of ice
o Carbon dioxide snow (dry ice)
o Feron 12
o Dichloro – diflouro methane
Carbon dioxide snow:
- Use of dry ice was described by ‘Ehrmann’
- Because the temperature of dry ice is – 78°C, pulp vitality can be
tested in teeth with full coverage restorations.
Responses to thermal tests
- The patient’s responses to heat and cold testing are identical because
the neural fibres in the pulp transmit only the sensation of pain.
These are four possible reactions the patient may have
a. No response
i. Indicates a nonvital pulp
ii. Possibly vital but gives a false +ve response due to
o Excessive calcification
o An immature apex
o Recent trauma
o Patient premedication
b. A mild to moderate transient thermal pain response which is
considered normal.
c. A strong painful response which subsides quickly after the
stimulus is removed signifies reversible pulpitis.
d. A strong painful response that lingers after stimulus is

removed, indicates a “sympatomatic irreversible pulpitis”.
1. Lack of reliability
2. Inability of child to understand the test
3. Fear of unknown makes the child apprehensive
4. Newly erupted teeth have incomplete innervations- may not
give correct results.
ELECTRIC PULP TEST:
- The electric pulp tester is designed to simulate a response by electric
excitation of neural elements with in the pulp.
- The electric pulp tester is a valuable tool for diagnosis; as it helps the
clinician in determining pulp vitality and also helps to distinguish
between pulpal, periodontal or nonodontogenic causes when used
along with radiographs and thermal test.
Although pulp vitality is dependent on intrapulpal blood circulation,
no practical clinical test has been devised to test circulation. The electric
tester, when testing for pulp vitality, uses nerve stimulation instead. The
objective is to stimulate a pulpal response by electric current. A +ve
response indicates vital pulp. No response indicates – pulp necrosis.
Technique (By Grossman)
a. Describe the test to the patient in a way that will reduce
anxiety and will eliminate a biased response.
b. Isolate the area of teeth to be tested with cotton rolls and a
saliva ejector, and air-dry all the teeth.
c. Check the EPT for function, and determine that current is
passing through the electrode.
d. Apply an electrolyte (tooth paste) on the tooth electrode,
and place it against the dried enamel of the crown’s occlusobuccal or
incisobuccal surface. Avoid contact with any restorations, adjacent

gingival tissue with the electrolytic or electrode, which causes a false
response.
e. Retract the patient’s check away from the tooth electrode
with the free hand which will complete the electric circuit.
f. Turn the rheostat slowly to introduce minimal current into
the tooth, and increase the current slowly. Ask the patient to indicate
when sensation occurs by using words such as “tingling” or “warmth”.
Record the result according to the numeric scale on the EPT.
g. Repeat the tests 2-3 times to avoid false readings.
Response to electric pulp test is affected by
a. Enamel thickness. Thicker the enamel more delayed the response.
Anterior teeth – yield a quicker response.
Posterior teeth – slow response
b. Patients level of anxiety / patient with an unusual high pain threshold.
c. Full crown restoration / teeth with extensive restorations.
d. Traumatized teeth / recently erupted teeth with incomplete root
formation.
e. Placement of probe tip.
f. Teeth with pulp protecting base and sedative medication.
False reading:
The results from electric pulp test should be misleading in certain
situations.
False readings are divided into two
i) False – Positive
ii) False – Negative
False positive – Readings means the pulp is necrotic but the patient feels the
sensation.
Main reasons for false positive response:
a. Electrode in contact with a restoration (full crown, amalgam) or the

gingiva allows the current to reach the attachment apparatus.
b. Patient anxiety: patient must be instructed about the procedure and to
raise the hand when he feels sensation.
c. Liquefaction necrosis may conduct current to the attachment
apparatus, (and the patient may raise his hand near the highest range).
d. Failure to isolate and dry the teeth properly.
e. In posterior teeth in which the pulp is partially necrotic with some
nerve fibres still vital in one or more canals.
False Negative: Reading means the pulp is vital but the patient appears
unresponsive Main reasons are:
1. Pre-medications (with analgesics, narcotics, alcohol etc)
2. Inadequate contact with the enamel.
3. Recently traumatized teeth.
4. Excessive calcification in the canal.
5. Dead batteries or if the pulp tester is not turned on
6. Recently erupted tooth with an immature apex
7. Partial necrosis.
Disadvantages
a. It gives no indication of the state of vascular supply, which would
give a more reliable measure of the pulp vitality.
b. Readings taken from posterior teeth may be misleading because some
combination of vital and non vital root canal pulps may be present.
c. It cannot be used in patients with cardiac pacemaker because of
potential interference with the pacemaker.
d. Response not achieved correctly when gloves are worm.
e. Cannot be used for recently traumatized and immature apex. As
response is not proper.
f. It should not be done on teeth with full coverage restoration because

an electric stimulus cannot pass undistorted through acrylic, ceramic
a metallic portions of crown.
g. Probe tip of EPT is removable and falls out easily.
Advantages
1. Intensity of stimulus is comfortable to the patients.
2. The digital display of many E.P.Testers provide instant, easy
and reliable information.
3. In some EP testers a red indicator light flashes on and off when
maximum stimulus is reached.
4. Gives a quantitative reading and can be compared with the
normal reading of control tooth.
Pediatric considerations – The value of electric pulp test in determining the
condition of pulp of primary teeth is questionable.
1. Lack of reliability.
2. Inability of child to understand the test.
3. Fear of unknown makes the child apprehensive.
4. Newly erupted teeth have incomplete innervations- may
not give correct results.
ANESTHETIC TEST: (GROSSMAN 1978)
- In the uncommon circumstance of diffuse strong pain of vague origin
when all other tests are inconclusive conduction, selective infiltration,
or intraligamentary aneasthesia can be employed to help identify the
source of pain.
- The basis for this test lies in the fact that pulpal pain, even when
referred is almost invariably unilateral and stems from one branch of
trigeminal nerve.
Technique
- Using either infiltration or the intraligament injection inject the most
posterior tooth in the area suspected of being the cause of pain.
- If pain persists, anesthesize the next tooth mesial to it and continue to
do so until the pain disappears.
- If source of pain is not determined whether in maxillary or
mandibular give inferior alveolar block. If pain disappears it indicates
involvement of mandibular tooth and localization of pain is done with
intraligament injection.
Intraligamentary injection
- Most painful injection
- Administered in the distal sulcus of each suspected tooth.
- When involved tooth is anesthetize with this injection pain stops
immediately but for few seconds.
TEST CAVITY: (SELTZER & BENDER 1975)
- The test cavity involves slow removal of tooth structure to determine
pulp vitality.
- The test cavity is made by drilling through the enamel dentine
junction of an unanesthetized tooth.
- The cavity is prepared with a round bur at slow speed without a
coolant.
- This test is carried out only when other means have failed therefore
disadvantage of this test is iatrogenic damage.
- Pain or sensation felt by patient indicates vital pulp and thus the test
is performed on other teeth until the involved tooth is found.
OCCLUSAL PRESSURE TEST:
- One of the patients complaint is pain on biting.
Causes can be
- Acute apical abscess
- Periodontal abscess.
- Incompletely fractured tooth
Different methods used in this test are:
i. Cotton – wood stick
ii. Cotton – roll
iii. Tooth slouth – an autoclavable plastic device
iv. Rubber wheel-Burlew rubber disc.
- Diagnosis of incompletely fractured tooth is one of the most difficult
in endodontics.
- These above mentioned methods may help in detecting a fracture.
Cotton wood stick may reveal the split tooth.
The tooth slouth can be applied to the occlusal surfaces of various
cusps and the biting / chewing test can be gently repeated. At times the tooth
readily identifies the split tooth.
A rubber polishing disc can be used to confirm the presence of a
cracked crown when the patient bites on the disc, it acts as a wedge on the
cracked tooth and causes pain.
In case of “cracked tooth syndrome” – on biting (on cotton
application or rubber wheel) the fracture segments may separate, and pain
may be reproduced at intiation or release of biting pressure.
TRANSILLUMINATION:
- Emergence of the fiberoptic as a dental instrument has been a great
aid in the use of transillumination for diagnosis.
- The test requires shining a light from lingual / palatal surface.
- Transmission of powerful fiberoptic light through teeth helps to
detect interproximal caries and a fracture mainly the vertical.
- During this test operating light is switched off and fiberoptic light is
moved closed to neck of the tooth.
- Light does not pass through fracture, thus the part of tooth beyond
fracture remains dark.
- Fiberoptic light sources are available with rubber dam clamp
attachment
- Most reliable results are obtained if restorations are removed before
the examination.
ADVANCED / SPECIAL DIAGNOSTIC AIDS
- The present methods available for diagnosing the state of pulp are
crude and not fully reliable.
- Current research may well produce new ways of pulp testing.
Pulp hemogram (Guthrie & Baume)
- First drop of blood should be taken from exposed pulp & subjected to
a differential white cell count.
- Helpful in diagnosis of pulp vitality.
Photoplethysmography (Reich )
- This method involves passing light on tooth & measuring the existing
wavelengths using a photocell & galvanometer.
- If tooth with intact blood supply is warmed there should be vascular
dilation, & this would register as a current from the photocell.
Pulse – Oximetry (JOE Vol. 17, No. 10 Oct 1991 Pg-488)
- Pulse oximetry has emerged as the leading non – invasive monitoring
device for determining the oxygen (PO2) saturation and pulse rate of
patients under intensive care or during sedation procedure.
- The principle is simple in that light is passed from a photoelectric
diode across a part of the body and into a receptor.
The difference between the light received and light emitted is
calculated in a microprocessor to provide pulse rate and oxygen (PO2)
saturation readings.
Pulp oximeter used red and infra red wavelengths in order to

transilluminate a tissue.
Two wavelength of light are emitted from the diode to detect
oxygenated haemoglobin (arterial blood) and deoxygenated haemoglobin
(venous blood).
- It is the ratio of the absorbance of the wavelengths that provide
percentage of oxygenation of the blood.
- This method of determining O2 saturation through haemoglobin
concentration is extremely accurate as compared with former
methods of blood gas sample analysis.
- Lack of neuronal response does not always indicate pulpal death; this
test allows an immediate objective diagnosis of vascular integrity
without inducing painful stimulation.
Limitations:
1. Intrinsic – excessive CO2 in blood interfering with de-
oxygenation value.
2. Extrinsic – Movement of probe, Problems with probe itself.
Advantages
1. Verifies vitality in traumatized teeth as well as potential analysis of
the stage of pathological process of pulp.
2. Method is clearly superior to other vitality testing methods since it
does not rely on sensory nerve response.
- A probe developed for tooth testing was designed to consider the
curvature of teeth and thus prevents false reading from the distortion
of beam as it passed through a convex surface.
Laser Doppler Flowmetry
- Until recently pulpal blood flow measurement of intact human teeth
was vision.
- Tooth vitality is related to pulpal blood flow and not to the function of
sensory fibres as commonly tested by electric and thermal pulp tests.
- The first indication of the ability to measure pulpal blood flow non-
invasively using laser Doppler technique was shown in “1986 by
Gazelius et al”.
- Also it was demonstrated the laser Doppler technique was capable of
assessing tooth vitality by Olgart et al in 1988 and re-vascularization
of traumatized teeth by Gazelius et al 1988.
- Evaluates pulp vitality by measuring the velocity of RBC in
capillaries.
Laser Doppler flowmetry has two system
a. Closed system
b. Open system
Closed system
The equipment used was a periflux PF2, with a Helium – Neon laser
source emitting light at 632.8 nm.
- The probe fibres were of 0.75 mm diameter with a core seperation of
0.75mm.
As the light hits various components of the tissues it is partially
absorbed and partially back scattered.
The back scattered light has 2 components:
1. Light – back scattered from static tissues which has the same
frequency as the light going in
2. Light scattered from moving RBC’s is the Doppler shifted light with
a different frequency.
The back scattered light is processed and an output signal is produced i.e.
both the unshifted and shifted light is transmitted to a detector by optical
fibres where it is transduced / charged into electric current and processed.
The detected output signal can be fed into analog printer, or be read from a
digital board.
The combination of a silicon splint for immobilization of the probe
(closed system) and the use of 4 KHz signal bandwidth. Filter reduced the
movement artefact, while increasing the signal differentiation between vital
and non-vital teeth.
Advantage:
- This method ensures high accuracy of results.
Disadvantage:
- Technique is too complex
- Time consuming
Open System
To overcome the limitations of original technique (closed system) a
new instrument was developed known as LA VITAL (Sweden)
Technique
- This instrument was used in combination with a laser diode emitting
light at 750 nm
- This instrument uses a rigid probe that is hand held on the buccal
surface of the tooth during measurement (open system).
Advantages:
- Simple method
- Less time consuming
Disadvantages:
- The greater penetration of 750 nm laser increases the risk of signal
contributions from the surrounding tissues.
Advantages:
1. They are non – invasive
2. Simple to apply
3. Provide a continuous or near continuous record.
Disadvantages of LDF
1. It is impossible to calibrate them in absolute units and their outputs
may not be linearly related to blood flow. E.g. if the output signal
increases by 100% it cannot be assumed that the blood flow rate has
increased by 100%.
The fact that they cannot be calibrated in absolute units stems from
the fact that the signal derived from any one moving cell will depend upon
the distance of that cell from the recording probe, and this distance is not
known.
Note:
Avoid movements between the probe tip and underlying tissues to
avoid artefacts or false data. While examining the teeth the probe can be
fixed rigidly to tooth surface with some form of splints to avoid movements.
- These instruments provide a very valuable method for studying
pulpal blood flow, but data they provide must be interpreted with
care.
- A new method is ‘Excimer laser system’ emitting 308 nm for
residual tissue detection with in the canals (PINI et al 1989).
Dual wavelength spectrometry:
- Measures the oxygenation changes in the capillary bed rather than in
the supply vessels, hence not dependent pulsatile blood flow. It
detects the presence or absence of oxygenated blood at 760 nm and
850nm.
- It has some difficulty in detection of pulse as there is presence of
arterioles rather than arteries in the pulp also it is rigidly
encapsulatied by surrounding dentin and enamel.
Advantages:
- Useful not only in determining pulp necrosis, but also the
inflammatory status of the pulp.
- Non-invasive, objective, small and portable.

COMPUTED TOMOGRAPHY
- Computed tomography was introduced in Mid 1970.
- Computed tomography is a radiographic technique that blends the
concepts of this laser radiography with computer imaging
(computed).
- Techibana has reported about the use of X-ray CT in bucco-lingual
and mesio-distal widths of teeth and the presence or absence of root
canal filling materials and metal posts. Also observable are the
carious lesions, extension of the maxillary sinus and its proximity to
the root apices.
Advantages
1. Observations of structures, which are difficult to visualize with
conventional X-ray.
2. Provides images for 3-D reconstruction of roots, root canals and
teeth.
Disadvantages:
1. Expensive
2. Skin dose is large
3. Time consuming
MAGNETIC RESONANCE IMAGING
- Recently MRI has been tried out as a diagnostic tool in endodontics.
- MRI generates high quality cross – sectional images of the body.
- However, this needs very large equipment. The high electromagnetic
waves which are needed have not been approved of for use in
scanners. It is believed that MRI machine will be developed for
evaluation of odontogenic problems.
Advantages of MRI:
- Ionizing radiation is not used.
- High resolution images can be reconstructed in all planes.

- Excellent differentiation between soft tissue and between normal and
abnormal tissue
Disadvantages of MRI:
- Large and expensive equipment.
- Scanning time can be long .
- Contraindicated in patients with certain types of surgicalclips, cardiac
pacemakers, metallic restorations or ortho-appliances, aneurysms.
COMPUTERIZED EXPERT SYSTEM
- Reported by John Firriola
- Computerized expert system is used for the diagnosis of selected
pulpal pathosis viz.,
- Normal pulps
- Reversible pulpitis
- Irreversible pulpitis due to hyperocclusion
- Irreversible pulpitis
- Necrotic pulp
- Infection 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.
TACT (Tuned Aperture Computed Tomography) (Endodontic Dental

Traumotology 2000 Vol. 16 : 24-28).
- This is a relatively new type of imaging device that may have
advantages over current radiographic modalities in viewing an object
while decreasing the superimposition of the overlying anatomical
structures.
- The resulting image is made from a series of eight digital
radiographs that are assimilated into one reconstructed image.
- It is a charge coupled device (CCD) based technique.

- It consists of a standard radiographic unit, a digital image acquisition
device, and necessary TACT software to reconstruct the images.
Uses
1. Used to detect external root resorption mainly.
2. To detect recurrent dental caries.
3. To detect simulated osseous defects.
Advantages of TACT over conventional radiography
1. Detects small size defects
2. Less radiation exposure.
3. Localizes a lesion accurately.
4. Detects lesion in bucco-lingual dimensions.
Crown surface temperature changes
Vital teeth are warmer and rewarm quickly after cooling than non vital teeth.
I. Infrared thermographic imaging
II. Liquid crystal Testing
III. Hughes Probeeye Camera
COMPUTERIZED INFRA-RED THERMOGRAPHIC IMAGING (International
Endodontics Journal 2000 Sep 33 Vol. 2 : 443-447.)
- This technique is another non – invasive method of detecting the
surface temperature of a body.
- Crown temperature patterns of non vital teeth to be slower to rewarm
than that of vital teeth.
- It is highly technique sensitive and is still under research.
Liquid crystal Testing:
- Color change of Cholesteric liquid crystals are used to show
temperature difference between teeth with vital pulp( hotter) and
necrotic( cooler) pulp.
Hughes Probeeye Camera

- Used to assess pulp vitality which measures temperature changes as
small as 0.10ºc hence, been used to measure pulp vitality
experimentally.
Summary
- To conclude, one could say that the determination of the exact pulpal
status i.e. vital or necrotic is complex and is dependent on number of
factors viz, patient history, clinical examination and various
diagnostic tests conducted.
- However, with the advent of newer diagnostic techniques such as
pulse oximetry, laser Doppler flowmetry, and computerized
tomography that are more quicker, easier and precise diagnostic
means. The results of the newer diagnostic tests should never be
relied upon individually but on the contrary it should be utilized in
combination in order to arrive at a correct final diagnosis.
References
 Mc Donald and Avery: Dentistry for the Children and Adolecent, 9 th
ed.
 Shobha Tondon: Textbook of Pedodontics, 2nd ed.
 Cohen: Pathways of the Pulp, 6th ed.
 Ingle: Endodontics, 5th ed.
 Grossman LI. Endodontic Practice, 9th ed.
 Velayutham G. Assessment of pulp vitality: a review. IJPD 2009; 19:
3–15
 Thomas R. Pitt Ford. Technical equipment for assessment of dental
pulp status Endodontic Topics 2004, 7, 2–13
 J. Lin. Electric pulp testing: a review. IEJ 2008.
 Kells BE, Kennedy JG, Biagioni PA, Lamey PJ. Computerized

infrared thermographic imaging and pulpal blood flow: Part 1. A
protocol for thermal imaging of human teeth. Int Endo J 2000 Sep;
33(2):443-7.
 Nance RS, Tyndall D, Levin LG, Trope M. Diagnosis of external root
resorption using TACT (tuned-aperture computed tomography). Endo
Dent Traumatol 2000 Feb;16(1):24-8.
 Jenifer M. Schnettler, James A.W. Pulse oximetry as a diagnostic tool
of pulp vitality. JOE Vol. 17, No. 10 Oct 1991 Pg-488.

Endodontic DIAGNOSTIC METHODS

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Endodontic DIAGNOSTIC METHODS

Uploaded by

Copyright:

Available Formats

Endodontic diagnostic aids 219

ENDODONTIC DIAGNOSTIC AIDS

Whatever the reason patient’s chief complaint is the best starting

Acute reversible pulpitis Irreversible pulpitis

Nature Pain sharp lancinating perircing Dull, boring, gnawing

Duration Short duration disappears after Longer duration persists even

Response to Responds to cold Responds abnormally to

Localization Usually localized Diffuse

10. Occlusal pressure test

In hard tissue i.e. TEETH

(iii) Loss of translucency, slight colour changes, cracks may not be

- Excluding abscess formation associated with a periodontal disease,

Mobility – Depressibility testing:

- Performed with fingers or with an instruments when depressibility

viii. Resorption of cementum.

B. Lesion within the tooth.

(ii) Root fractures

- Acute apical periodontitis

d. A strong painful response that lingers after stimulus is

incisobuccal surface. Avoid contact with any restorations, adjacent

a. Electrode in contact with a restoration (full crown, amalgam) or the

f. It should not be done on teeth with full coverage restoration because

Pulp oximeter used red and infra red wavelengths in order to

- Non-invasive, objective, small and portable.

- High resolution images can be reconstructed in all planes.

TACT (Tuned Aperture Computed Tomography) (Endodontic Dental

- It is a charge coupled device (CCD) based technique.

Hughes Probeeye Camera

 Kells BE, Kennedy JG, Biagioni PA, Lamey PJ. Computerized

You might also like