Al-Quds University – Faculty of Dentistry

Second semester 2020/2021

Endodontics course (1104109)

DIAGNOSIS OF PULPAL AND PERIAPICAL PATHOSIS

Baha’ M. Ewissat (21620001) & Moh’d M. Halasi (21620002)

Supervisor: Dr. Basem abu qubi

*Introduction:
Endodontic steps are Diagnosis, rubber dam isolation, access, root
canal preparation, root canal filling, coronal restoration and follow-
up. Diagnosis and treatment planning are common elements in all
disciplines of dentistry. The majority of pulp and peri-radicular
pathosis is asymptomatic (about 90% of them), and 10% are
associated with symptoms (pain). Clinician must able to differentiate
pulpal and peri-radicular problems from other pathologic entities,
examples: Atypical facial pain, acute maxillary sinusitis, cluster
headaches …etc.
*How ensure correct diagnosis?
To ensure a correct diagnosis, the clinician must collect an accurate
database: obtaining a medical & dental history, performing a clinical
examination and relevant tests and making appropriate radiographs.
Step-by-step are biographical details, medical history, chief
complaint, history of present complaint, dental history, social history,
extra-oral examination, intraoral examination, special tests,
Radiographs, Diagnosis and treatment plan.

Biographical details include Patent's name, gender, age, occupation,

……etc. getting to know the patient so you will earn his trust.

Obtaining a written medical history is mandatary and should precede

the examination and treatment of all patients. Information regarding
current medications, allergies, diseases, psychological status …. etc.
Is important in diagnosis, because the patient may have systemic
disease with oral manifestation. Moreover, a systemic disease may
present initially as an oral lesion.

Dental history Allows the clinician to build rapport with the patient.
The dental history should include the chief complaint and a history of
the present illness if the patient has signs and/or symptoms of disease.

*Diagnosis:
Include all of the following: questioning, visual diagnosis
(examination), regular test (probing, percussion, palpation &
movement (mobility), special test (electro-vitality test + thermo-
vitality test) and supplementary test (cavity test, bite test, selective
anaesthesia & transamination / dye staining).

Question the patient regarding the inception, location, type,

frequency, intensity, duration, and cause of any pain or discomfort to
develop a differential and definitive diagnosis. Pain is a complex
physiologic and psychologic phenomenon and often cannot be used to
differentiate endodontic problems from non-endodontic pathosis.

Visual inspection of the soft tissues should include an assessment of

color, contour, and consistency. Localized redness, edema, swelling,
or a sinus tract can indicate inflammatory disease. Examination of the
hard structures may reveal clinical findings such as developmental
defects: caries, abrasion, attrition, erosion, defective restorations,
fractured cusps, cracked teeth, and tooth discoloration.

regular test includes: probing, percussion, palpation and movement

(mobility). First of all is probing, Endodontic and periodontics lesions
may mimic each other. isolated probing defects include periodontal
disease, periapical pathosis forming a sinus-like trap through the
periodontium, developmental defects such as a vertical groove defect,
cracked teeth and vertical root fractures, and external root resorption.
Then we do palpation, digital palpation of the soft tissues over the
apex of the root. Palpation of the buccal and lingual soft tissues can
detect of sensitivity and swelling areas. And about the mobility,
placing an index finger on the lingual surface and applying lateral
force with an instrument handle from the buccal surface.

Special (diagnostic) pulp testing, Electrical and thermal testing

procedures have been shown to produce reliable results. Thermal
testing, testing with hot and cold identifies whether the pulp is normal
or inflamed, Cold testing is usually performed first, Using ice or
endo-ice spray. The steps are, Complete isolation to area, using cotton
roll. Then, drying the buccal surface, using gauze. Then, comparing
(start with the normal teeth) then test the abnormal teeth, using
tweezer with cotton pellet. (on middle + cervical area). The patient
will have complained of pain immediately after application, and the
pain doesn’t linger with normal tooth (immediately after removal of
ice, so will be no pain), but if there is a pathosis the patient will have
complained {acute sever pain}, the pain lingers for 10-20 second only
so pulp is vital but not completely normal. If no response so the pulp
is necrotic. In addition to, heat test, Using heated gutta-percha. if no
response to heat of cold so the tooth is totally necrotic. Also we can
use electro-vitality test, Assistant factor (less important than thermal
pulp testing), using (pulp tester), stimulate a-delta fibers (maturation
after 5 years of eruption), don’t do it until after 5 years have passed of
eruption of tooth.

Supplementary tests include: cavity test, bite test, selective anasthtesia

and trans illumination / dye staining.

*Radiographs:
At the end, radiographs, uses to confirm the diagnosis and are include
extra-oral (panoramic + CBCT) & intra-oral (periapical + bitewing).

*conclusion:
In order to render proper treatment, a complete endodontic diagnosis
must include both a pulpal and a periapical diagnosis for each tooth
evaluated. Endodontic diagnosis is similar to a jigsaw puzzle.
diagnosis cannot be made from a single isolated piece of information.
The clinician must systematically gather all of the necessary
information to make a “probable” diagnosis. When taking the medical
and dental history, the clinician should already be formulating in his
or her mind a preliminary but logical diagnosis, especially if there is a
chief complaint. The clinical and radiographic examinations in
combination with a thorough periodontal evaluation and clinical
testing (pulp and periapical tests) are then used to confirm the
preliminary diagnosis.
(3)