DIAGNOSIS IN

ENDODONTICS
 INTRODUCTION
Diagnosis is the process of identifying a
disease by careful investigation of its
symptoms and history.
An accurate diagnosis is the result of
synthesis of scientific knowledge, clinical
experience, intuition and common sense. The
process is thus both an art and science.
 ENDODONTIC TRIAD
HISTORICAL CONTEMPORARY

DIAGNOSIS
DEBRIDEMENT

SUCCESS
SUCCESS

STERILIZATION APICAL SEAL ANATOMY & 3D OBTURATION

DEBRIDEMENT
 The four components of diagnostic
procedure are
1.Assemble all available facts
Chief complaint
Medical & Dental history Subjective symptoms
History of the present condition
2. Screen & interpret the assembled clues and discover which
are genuine to the case
3. Differential Diagnosis
4. Operational or working diagnosis which is the final
diagnosis
 PATIENT QUESTIONNARE
First Name:______________ Last Name:_______________
1. Are you experiencing any pain at this time? Yes ___ No ___
2. If yes, can you locate the pain? Yes ___ No ___
3. When did you first notice the symptoms? ________________________
4. Did symptoms occur suddenly or gradually? _____________________
5. Do you grind or clench your teeth? Yes ___ No ___
6. If so, do you wear a night guard? Yes ___ No ___
7. Has a restoration (filling 0r crown) been placed on this
tooth recently? Yes ___ No ___
8. Prior to this appointment, has root canal therapy been started on this tooth? Yes ___ No ___
9. Any past trauma or injury to this tooth? Yes ___ No ___
10. If yes, describe past trauma and state the occurrence date.
__________________________________________________________
11. Is there anything else about your teeth, gums or sinuses.
__________________________________________________________
Please check the frequency, quality and intensity of your pain
LEVEL OF INTENSITY FREQUENCY QUALITY
1__ 2__ 3__ 4__ 5__ 6__ 7__ 8__ 9__ 10__ Constant__ Sharp__
Intermittent__ Dull__
Momentary__ Throbbing__
Occasional__
 SUBJ ECTI VE INFORMATI ON
History of pain
Stimulus of pain
Frequency of pain
Severity of pain
Duration of pain
Spontaneity of pain
Location of pain
Character of pain
Alleviation of pain
OBJ ECTI VE I NFORMATION
Visual examination
Percussion and palpation
Caries and fractured
restorations
Sinus tracts
Tooth fractures
Extensive restoration
Exposed dentin, wear facets
Periodontal disease, mobility

RADI OGRAPHI C ASSESSMENT COMPARATI VE TESTI NG

Tooth length, no. of roots Thermal tests
Calcifications, orifice location Electric pulp tests
Number of canals, radiolucencies Anesthetic test, test cavity
Resorptions, fractures Transillumination

ASSESSMENT OF PULP AND PERI RADI CULAR TI SSUES

PLAN OF TREATMENT
 CHIEF COMPLAINT
Listen to your patient. He is trying to tell you what
is wrong with him. (Sir William Osler)
Chief complaint is the history of the symptoms
noted in the patients own words that describes the
symptoms causing the discomfort.
 A proper diagnosis begins with information
about the patients chief complaint, along with the
objective findings found through clinical and
radiographic examinations coupled with
appropriate pulp tests.
Compare the patients signs and symptoms and
test results to known disease entities in the
differential diagnosis and select the closest match,
which becomes the operational or working
diagnosis.
 An astute clinician always remains open to
further input that could modify the diagnosis
and potentially the treatment as the unfolding
of the information progresses.
The importance of accurate diagnosis cannot
be over emphasized.
 PAIN

The alleviation of dental pain is one of

the prime objective of the dental
profession.
Management of pain is to establish
diagnosis and treat the condition
efficiently and effectively.
Often diagnostic decisions concerning the pulpal
status is based on symptoms alone e.g. an
irreversible disease state - immediate treatment or
a reversible disease state - palliative treatment or
observation .
Wait & Watch approach is adopted in the
following conditions

1. Short term sensitivity or discomfort

2. History of recent dental treatment or loss of
restoration or possible fractured cusp.
 Definitive pulpal treatment is indicated
when the following conditions are present

1. History of moderate or severe pain with

recurring episodes of spontaneous pain over
long period of time.
2. Painful symptoms produced by specific
stimuli such as biting /taking hot or cold
food.
 CLINICAL EXAMINATION

VISUAL EXAMINATION:
Extra oral examination
Intra oral examination
Soft tissues:
Color
Contour
Consistency
Sinus opening
 VISUAL INSPECTION
COLOUR
Normal crown- life like translucency
Discolored opaque inflamed, degenerated or
necrotic pulp.
Calcified Canal Light Yellow Hue of the Crown
Pink Tooth Indicates Internal Resorption
CROWN CONTOUR
Wear Facets, Fractures and Restorations
Caries Examination
Diagnodent is useful for early caries diagnosis.
 PALPATION
Digital pressure is used to check for tenderness
in the oral tissues overlying the suspected
teeth.
Bimanual palpation is most efficient to detect
incipient swellings before it is clinically
evident.
 PERCUSSION
Normal resonant sound on percussion indicates
good periodontal ligament
Dull sound on percussion indicates ankylosis.
Response to percussion not only indicates the
involvement of the PDL but also the extent of
the inflammation.(degree of response directly
proportional to degree of inflammation).
Chronic periapical inflammation is often
negative to Percussion.
Inflammation of the PDL may be caused by
occlusion, trauma, sinusitis, periodontal
disease or extension of pulpal disease .
Percussion is not a test of pulp vitality.
 PERIODONTAL
CONSIDERATIONS
Periodontal probing should be carried out by
sounding or walking the probe around the
tooth, while pressing gently on the floor of the
sulcus.
Horizontal bone loss with generalized pocket is
not as worrisome as isolated vertical bone loss
which frequently indicates vertical root
fracture.
 MOBILITY
Tooth mobility provides an indication of the
integrity of the attachment apparatus.
Causes may be recent trauma, crown/root
fracture, chronic bruxism, habits and
orthodontic tooth movement.
Grade I Noticeable horizontal movement in its
socket.
Grade II within 1 mm of horizontal movement.
Grade III Horizontal movement greater than 1
mm and/or vertical depressibility.
 As we move forward in this new millennium the
science of endodontology (endodontics) has
reached its leaps and bounds. The pathway to
the most probable diagnosis was enhanced
significantly with the popularization of electric
pulp testing and availability of information from
the dental radiographs.
OTTO WALKOFF who took the first dental
radiograph and EDMUND KELLS used it for
diagnosis during root canal treatment deserve a
mention for their pioneering work in our field.
 RADIOGRAPHS
Radiographs are an important and necessary adjunct
in Endodontics. Periapical and Bite wing
radiographs are mainly used.
Accurate radiographic techniques and proper
interpretation are essential for sound diagnosis and
treatment.
Radiographs are used for determining pulpal
anatomy prior to access openings.
Establishing working length.
Confirm master cone placement and for evaluating
the success of treatment.
Bite wing radiographs are helpful to
Detect recurrent decay
Detect the depth of pulp chamber.
Peri radicular pathosis / bone destruction is
not evident in the radiograph, until there is
significant erosion of the cortical plate because
bone loss is confined to the cancellous bone.
With a mineral content of 52% of the cortical
bone, there must be a 6.6% loss of bone
mineral in order for the lesion to become
radiographically visible.
 Features seen in high quality periapical
radiographs (ortho radial projection) include
caries
Sharp outline of the root
Tooth length
Number of roots and canals
Calcification
Hard tissue deposits
Internal/External resorption
Periapical lesions
Perforations
Fractures
 CARIES
Caries progression is divided into five
radiographic grades
Grade 1 Caries in enamel
Grade 2 Reaches the DE junction
Grade 3 Radiolucency extends halfway
into dentin thickness
Grade 4 Deeper dentin
Grade 5 involving the pulp
 Caries Examination
Receding pulp horn age changes,
chronic carious lesion
In Posterior teeth,
Mesial Carious Lesion more
commonly involves pulp,
Distal Carious Lesion Silent Killer
takes a longer time.
Deep caries involvement of mesial
Pulp horn causes minimal periapical
changes either in mesial/distal root.
 The morphological features to be noted
regarding root canal anatomy
Length longer or shorter
Shape Blunder buss
Taurodontism
Dens in Dente
Root with bulbous ends
Curved canals Degree of curvature
X-ray exposed at 15 horizontal angle can help
visualize curvature in bucco-lingual plane.
 Number of canals
Always look and expect for extra canals
(Mandibular Incisor & Premolar, Maxillary
First Molar)
When large canals stop abruptly, look
for branching
Resorption
Internal resorption Continuous with canal
External resorption Super imposed.
Calcification
Can be either isolated or continuous
FRACTURES
Vertical Root Fractures
- Cannot be seen through radiographs
- Look for haziness surrounding the roots
Transillumination
Fiber optic wand, otoscope with fiber optic
attachment or fiber optic hand piece may be used.
Composite curing lights are not recommended as they
may illuminate the entire crown and not highlight the
fracture line as with fiber optics.
Tooth slooth
Horizontal and oblique fractures
- Two x-rays are needed to locate
these fractures
 Things to look for in radiographs
Cervical burnout :
It is a diffuse radiolucent area on the proximal
side. Decreased x-ray absorption in that area
should not to be confused with root caries.
Lamina dura:
Parallel well defined
Oblique diffuse
Thickened/dense Heavy occlusal forces
Intact lamina dura Vital pulp
 Alveolar Crest:
- Normal 1.5 mm from the C-E junction
- Crest of bone is continuous with the
lamina dura and forms a sharp angle
with junctional epithelium
- Rounding of this sharp junction
indicates periodontal disease.
Periodontal ligament space
- Space is thinner in middle of the root
and widened near alveolar crest and
root apex.
NORMAL ANATOMIC LANDMARKS IN
MAXILLA

INTERMAXILLAR
Y
SUTURE

Seen between
incisors
ANTERIOR NASAL SPINE

Seen in the midline

 NASAL FOSSA

Seen in the midline

above the anterior
nasal spine.
 INCISIVE FORAMEN

Symmetrical
Variable position
May be present at
the apex of the
central incisor
roots and even up
to the alveolar
crest.
SUPERIOR FORAMINA OF
NASOPALATINE CANAL

Occasionally
appear when
exaggerated
vertical angle is
used.
 MAXILLARY SINUS

Close proximity of
root apices to
maxillary sinus.
 MANDIBLE
SYMPHISIS
GENIAL TUBERCLE Seen in occlusal
radiograph.
MENTAL FOSSA Present in the labial
aspect of mandible.
MENTAL FORAMEN - Seen half way
between lower border of mandible and crest of
alveolar process, usually in the region of apex
of second premolar and its position is
influenced by angulation.
 MANDIBULAR CANAL

Continuous with the

apex of third molar
Distance from root
increases as it
progresses anteriorly
Appears as tram lines in
the radiograph.
 LIMITATIONS OF RADIOGRAPHS
Radiograph is a two dimensional
representation of a three dimensional object.
Hence magnifying loupes are recommended
for more exact interpretation.
Radiographic misdiagnosis if there is only
buccal/ cervical involvement (deep caries)
Besides diagnostic radiograph, additional
radiographs are necessary depending on
specific situations.
This can be overcome by the tube shift
technique, in which two films are taken in
same vertical angulation and 10 - 15
change in horizontal angulation.
This projection helps to
Superimposed canals can be separated
Locate perforations
Lesions that appear attached to the root will
move away when the projection is changed.
Vertical shift of tube enables to visualize the root
apices which are superimposed by the zygomatic
arch.
Other films like
Panograms
Lateral jaw projections
Occlusal radiographs
are also useful in determining the three
dimensional extent of a lesion.
Another limitation of radiographs is
interpretation.
All meanings, we know, depend on the
key of interpretation - EAST
Radiolucency at Furcation Area
May be due to,
Periodontal Involvement,
Accessory Canals,
Cervical Pulp Horn.
 Points to be checked during radiographic
interpretations include

Clear films / Additional films

Is root canal system within normal limits
(Calcifying or resorbing)?
Is lamina dura intact or not?
Is bony architecture within normal limits?
What anatomical landmark can be
expected in this area?
 Digital Radiography (RVG)
Reduced radiation exposure 80% less
Immediate availability of image
No need of processing materials
Ability to store data
Relief image or contrast image
 PULP VITALITY TESTS

Assessment of vitality using routine methods

rely on the stimulation of A nerve fibers and
there is no direct indication of the blood
flow.
Three methods are used to stimulate the A
nerve fibers
1. Thermal stimulation
2. Electrical stimulation
3. Direct dentin stimulation.
 THERMAL STIMULATION
Inexpensive
The temperature used is 65.5C
to elicit the response
Can use Gutta percha (base
plate gutta percha)
Cast metal crown restorations
are too thick to allow heated
GP to elicit response
In such cases a rubber wheel is
used to elicit the response
 COLD TEST
Various materials used for cold
test are
Cones of ice - -20C
Ethyl chloride spray - - 40C
Carbon- di- oxide snow
-70C
Application of cold for 4 seconds
lowers the temperature to between
26 and 30C eliciting pain.
Within the pulp temperature is
lowered by 0.2C.
Heat causes vasodilatation and increase in intra
pulpal pressure (releases gaseous product of
proteolysis) (VAN HASSEL).
In an intact pulp specific pulpal temperature
must be reached before there is pain from heat.
Therefore, application of heat to normal teeth
gives delayed response.
In a tooth with inflamed pulp, increased intra
pulpal pressure already exists. Therefore
immediate painful response to gradual/sudden
increase in heat.
 COLD
Cold decreases intrapulpal pressure in normal intact pulp and
there is no pain.
The pain from cold is due to hydrodynamic mechanism.
Contraction of fluid causes outward flow of fluid in dentinal
tubules, deforms A nerve and an action potential is
generated.
In advanced acute pulpitis, no A receptors are present. Cold
produces contraction and lowers the intrapulpal pressure to
a sub threshold level and relieves pain due to still viable C
fibers.
Pain returns within 30 60 seconds as intra pulpal pressure
returns to its former suprathreshold level.
 ELECTRIC PULP TEST
Electrolyte applied on the teeth to transmit
current
Jelly used for ECG is ideal
When electrolyte contacts the tooth an
electric charge is applied by pressing rheostat
button. A small charge is released initially
and increased until response is felt.
Select control teeth contra lateral teeth and
adjacent teeth.
 INTERPRETATION
If the current required to gain a response from a
test tooth is same as that needed to excite the
control the pulp of the test tooth is considered
normal.
If less current is required for a response
Hyperactive
If more current is required delayed response/
high pain threshold
Lack of response Pulpal necrosis
 Two readings are recorded and the average
value is taken.
Using EPT on any tooth more than 4
times can give wrong reading due to
additive action.
 Only A fibers are activated by electric tests
A fibers produce initial momentary sharp
response to electric stimuli because of its
peripheral location, low threshold & greater
conduction velocity.
Continuous constant pain is produced by the
smaller C fiber stimulation as it is associated
with tissue damage and inflammatory process.
 DISADVANTAGES
Battery plug in
Electrical deficiencies
Output current variations
Battery run down and not delivering full
current
all these give variable results with EPT
Molars give readings not indicative of the true
pulpal condition.
 LIMITATIONS

Tests are not reliable on immature teeth of

young patients as these teeth contain fewer A
fibers than mature teeth and myelinated nerves
do not reach their maximal depth of
penetration into the pulp until the apex
completes its development.
 When comparing teeth in question with the
control teeth, pulps of the control teeth may
not be normal.
Teeth with acute alveolar abscess may respond
positively to EPT because the gaseous and
liquefied elements within the pulp can transmit
electric charges to periapical tissues.
 In traumatic injuries, in the cervical
areas there will be temporary
paraesthesia of the nerves. If pulp
vitality remains, the pulp will respond
within normal limits after 30 to 60
days.
 Current methods of stimulation of A
fibers give no direct indication of the blood
flow within the pulp.
These methods are all subjective tests that
depend on patients response to stimulus as
well as dentists interpretation.
Assessment of the blood flow is the ideal
test for vitality.
 Research is the primary catalyst to
professional growth and has greatly added to
the understanding of the etiology,diagnosis
and treatment of dental diseases.
 PULSE OXIMETRY
It is a non invasive oxygen saturation device
for recording blood oxygen saturation levels.
Based on BEERs law Absorption of light
by a solute to its concentration and its optical
properties at a given wave length.
The system consists of probe with diode that
emits light in two wavelengths.
Red light of approximately 600 nm
Infra red light of approximately 850 nm
Detects presence or absence of oxygen in
blood at 760nm/860nm.
LASER DOPPLER FLOWMETRY
Based on the principle that reflected light from
blood flow will demonstrate a Doppler effect,
depending on the relative velocity of the blood flow
& probe.
There are two types
a) Direct laser Doppler flowmetry.
b) Indirect laser flowmetry.
 SPECIAL TESTS
The apt test for teeth restored with composite eliciting
features of pulpitis is the cold test.
In teeth with full crown coverage hot water/ coffee test .
Wedging and staining
methylene blue, erythrosine dye.
Selective anesthesia test
Intra ligamentry anesthesia into the distal
sulcus provides relief of pain in the affected tooth.
 Test Cavity- The Confirmatory
Test
Teeth that exhibit mixed response to pulp
testing - confirmed with Test Cavity.
Teeth with ceramic crown test cavity is done
on the Palatal aspect for anteriors & Occlusal
for posteriors.
 Difference between pulp and
periodontal disease
Pulpal Periodontal
Cause Pulp infection Periodontal
infection
Vitality Non vital vital
Restorative Deep or Not related
extensive
Plaque/calculus Not related Primary cause
Inflammation Acute chronic
Trauma Primary or Contributing
secondary factor
 DIFFERENTIAL DIAGNOSIS

The step in diagnosis to distinguish one

disease from several other similar diseases
by identifying their differences.
 CLI NI CAL CHARACTERI STI CS OF
REVERSI BLE PULPI TI S
Sensitivity to mild discomfort
Short duration or shooting sensation
Not severe
Infrequent episodes of discomfort
Common causes include exposed dentin, cracked
restorations, recently placed restorations, initial
carious attack or rapidly advancing caries, altered
occlusion
Could result in irreversible pulpitis if cause not
removed
Symptoms usually subside immediately or shortly after
removal of the cause
 CLI NI CAL CHARACTERI STI CS OF
I RREVERSI BLE PULPI TI S
Pain may be absent or present
If present, pain is moderate to severe
Pain is often spontaneous, increasing in frequency,
often to a point of being continuous
Pain usually lingers, especially with increasing
episodes
Thermal stimulation often elicits severe lingering pain
Pain radiates or is diffuse or may be localized
History of trauma, extensive restorations, periodontal
disease or extensive recurrent caries is present.
 CLINICAL CHARACTERISTICS OF
SUB - ACUTE PERIRADICULAR
PERIODONTITIS
Slight tenderness to biting or percussion
No lesion present on radiographs
 CLI NI CAL CHARACTERI STI CS OF
ACUTE PERI RADI CULAR
PERI ODONTI TI S

Pain to biting or percussion

No thickened ligament space or lesion
present
Tooth may be mobile
Often tender to palpation
 CLI NI CAL CHARACTERI STI CS OF
CHRONI C PERI RADI CULAR
PERI ODONTI TI S

Patient asymptomatic
If sinus tract present, referred to as
suppurative
Percussion produces little or no discomfort
 CLI NI CAL CHARACTERI STI CS OF
ACUTE ALVEOLAR ABSCESS

Severe pain with biting, percussion and

palpation
Tooth elevated in the socket
Tooth very mobile
Swelling may be present
Often systemic symptoms present
 CONCLUSION
With proper integration of clinical and
radiographic factors, in an environment
that minimizes the shackles of bias, the
wise and prudent clinician will be able to
assess both the process and completed
treatment.