DIAGNOSIS IN

ENDODONTICS
Subjective information
Objective information
 Medical history

 Antibiotic prophylaxis (hart valve replacement,

rheumatic fever, chemo- or radiotherapy);
 Special protection for the dentist (Hepatitis,
AIDS, herpes)<
 Consult with the patient`s physician.
 Endodontic Diagnosis
 Subjective examination
 Chief complaint
 Character and duration of pain
 Painful stimuli
 Sensitivity to biting and pressure
 Discolouration of tooth
 Important questions?
 What do you think the problem is?
 Does it hurt to hot or cold? 
 Does it hurt when you’re chewing?
 When does it start hurting?
 How bad is the pain?
 What type of pain is it?
 How long does the pain last?
 Does anything relieve it?
 How long has it been hurting?
 Objective examination

 Facial symmetry, cutaneous fistulae, soft tissues;

 Oral hygiene,
 Hard tissues (decay, extensive restorations);
 Periodontal conditions surrounding the tooth in
question, tooth mobility;
 Swelling or discoloration;
 Pulp exposure.
 Diagnostic Tests
 Percussion
 Palpation
 Thermal
 Electrical
 Radiographs
 1. Percussion tests
 Presence of periapical inflammation;
 Tapping on the incisal or occlusal surface of the
tooth with the handle of an instrument;
 Positive/ negative;
 Contraindicated when a fracture is suspected.
 2. Palpation tests

 Used to determine whether the inflammatory

process has extended into the periapical tissues
 The dentist applies firm pressure to the mucosa
above the apex of the root
 3. Thermal sensitivity

Necrotic pulp will not respond to cold

or hot

1. Cold test
 Ice, dry ice, or ethyl chloride used to
determine the response of a tooth to cold
2. Heat test
 Piece of gutta-percha or instrument
handle heated and applied to the facial
surface of the tooth
 Thermal tests

 Pain is influenced by cold/hot stimuli;

 Patient is informed about the reason and type
of stimuli, its effect and how to communicate
with the dentist;
 The pulp has no specific receptors for heat or
cold, it will respond the same (with pain)
 Begin with 1-2 healthy teeth, in order to have
the reaction of a healthy dental pulp.
 Heat test
 Heating a piece of gutta-percha a few swcond
above a flame (recommended 650C);
 Applied buccal , on middle 1/3 of the crown;
 Evaluates dentinal sensitivity and is applied
where the enamel is thinnest;
 Normal: mild sensibility, immediately recedes;
 Pulpitis: intense, prolonged pain!
 Full crown tooth – heat from a rubber disc.
Heat test
Heat test
 Cold test
 Low risk of inducing further dental pulp
lesions;
 Ice sticks, ethyl chloride;

 Cold water or ice Risk of False +

 Start with lower arch

 Ethyl chloride:

Spray on cotton, remove excess,

apply buccal in the
middle 1/3 of the crown.
 Important

 Tooth must be isolated and dry!

 Ethyl chloride is very inflammable;
 Do not spray directly on the tooth;
 Keep the cotton pellet a few seconds in contact
with the dental surface;
 Could be used in teeth covered with metal
crowns.
 Evaluation of thermal test results
4 distinct responses:

1. No response non-vital pulp or

false negative

2. Mild response normal

3. Strong but brief reversible

4. Strong but lingering irreversible

 4. Electric pulp test
 Stimulates the neural elements of the pulp;
 No information about the status of blood
supply;
 Alive and healthy OR viable but diseased;
 Must be used in association with other tests,
due to many false +/- responses;
 Not indicated in patients with PACEMAKER !
 Method: isolation, dried tooth, start and
compare with healthy teeth.
 Causes of false + responses
 Contact with gingiva or large amalgam
restorations
 The patient is anxious
 Liquefaction necrosis
 The dental pulp is not completely destroyed
(molar teeth – one canal is vital);
 The tooth is not dry or well isolated.
 Causes of false - responses

 The patient is premedicated

 Inadequate contact with the enamel
 Recent trauma
 Heavy calcefication of the canal
 Immature apex.
 Cavity test
 Prepare a small cavity without anesthesia
 This test is used if:
 Other tests were contradictory;
 Deep carious lesions restored with thick bases
 Color change
 Abraded teeth in old patients.
 Anesthesia test
 Anesthesia of a single tooth
 Intraligamental injection
 Anestezie tronculară periferică (Spix)
 Challenges in diagnosis of pulpitis
 Referred pain & the lack of proprioceptors in
the pulp localizing the problem to the
correct tooth can often be a considerable
diagnostic challenge
 Also of significance is the difficulty in relating
the clinical status of a tooth to histopathology
of the pulp in concern
 Unfortunately, no reliable symptoms or tests
consistently correlate the two.
 Transilumination
 Anterior teeth – pink
spot at crown level;
 Necrotic tooth - opac

 Corono-radicular
fractures
(transilumination, bite
test).
Vital tooth/necrotic tooth
 Traumatism
MODIFICARE DE CULOARE, DEPUNERE DE OBLITERARE, LEZIUNE
DENTINĂ ÎN CAMERA PULPARĂ (3 ANI) PERIAPICALĂ CRONICĂ (10 ANI)
Presence of blood flow in the dental pulp
 laser Doppler  They rely either ON:
flowmetry (LDF) The detection of changes in
 Pulse oximetry the light absorption as it
passed through the tooth -
 dual wavelength
spectrophotometry pulse oximetry and DWLS.
(DWLS)
 OR
 Surface temperature The shift in light frequency
as it is reflected back from
a tooth, as in LDF.
 Dual Wavelength Spectrophotometry
 DWLS is a method independent of a pulsatile
circulation.
 The presence of arterioles rather than arteries
in the pulp and its rigid encapsulation by
surrounding dentine and enamel make it
difficult to detect a pulse in the pulp space.
 This method measures oxygenation changes in
the capillary bed rather than in the supply
vessels and hence does not depend on a
pulsatile blood flow (BF).
 Dual Wavelength Spectrophotometry
 Even though the instrument was not
specifically designed for dental use, it can be
developed as a pulp tester. A major advantage
is that it uses visible light that is, filtered and
guided to the tooth by fiber optics. Thus unlike
laser light, added eye protection is unnecessary
for the patient and the operator.
 The test is noninvasive and yields objective
results.
 Pulse oximetry is a method based on DWLS.
 Pulse Oximetry
 The pulse oximeter is a well‑accepted,
noninvasive oxygen saturation monitoring
device widely used in medical practice for
recording blood oxygen saturation levels
during the administration of intravenous
anesthesia.
 It contributes to the increased safety of general
anesthesia. Pulse oximetry is an entirely
objective test, requiring no subjective response
from the patient.
Pulse Oximetry
 Pulse Oximetry

 A number of clinical studies have proved that

the pulse oximetry is an effective and objective
method of evaluating dental pulp vitality in
primary as well as permanent teeth.
 Laser Doppler Flowmetry
 LDF is a noninvasive, electro optical technique,
which allows the semi‑quantitative recording
of pulpal BF.
 Its use in teeth was first described in 1986.
Since then, the technique has been widely used
to monitor dynamic changes in pulpal BF in
response to pressure changes and following
administration of local anesthesia.
 The Laser Doppler technique measures BF in
the very small blood vessels .
Laser Doppler Flowmetry
 LDF probe placed at
2mm above the bucal
CEJ is transmitted
apically towards the
radicular pulp.
 LDF has been shown to
be valuable in
monitoring
revascularization of
immature incisors
following severe dental
trauma.
 Laser Doppler Flowmetry

 The limitations of this method include a too

expensive device for use in a dental office. It is
technique‑sensitive: Its readings are affected by
the movement of the patient, a nonfixed probe
or a mobile tooth. It takes about an hour to
produce recordings, making it impractical for
dental practices.
Surface Temperature Measurement
 In 1985 a laboratory study showed that it is
possible to differentiate by means of crown
surface temperature, distinct differences in
vital and nonvital teeth.
 Further research is being undertaken with the
sole aim of increasing the detectable difference
between vital and nonvital teeth, so that a
method of temperature measurement may be
evolved which is of diagnostic significance
under routine clinical conditions.
 Conclusions
 Recording the pulpal BF would be an objective
indicator of pulp vitality.
 The advantages are: objective, noninvasive and
atraumatic testing modalities, with greater
patient acceptance and co‑operation.
 Currently, no vitality tests have been proven to
be superior in all aspects compared to pulp
sensitivity tests. Hence, sensitivity testing even
with its limitations has been and remains a
very helpful aid in endodontic diagnosis.
 Conclusions
 Many studies were carried out to compare LDF
with conventional pulp tests, EPT and thermal
tests, in children with certain dental injuries
which showed that LDF was significantly
better at 3, 6, and 12 months compared to
others. It identified more vital and nonvital
teeth correctly at earlier time periods following
injury than conventional tests.
Questions????