1. 1
Diagnosis
Pulp Pathosis
Process of making a diagnosis
5 stages
1. Patient says why they have presented
2. Clinician probes with ??? – history of
problem – symptoms related to current
condition
3. Clinician performs OBJECTIVE tests
4. Correlation of Objective and Subjective
data
5. Definitive diagnosis
Adopt a systematic approach
Carefully engineered ????
Elicit critical and pertinent data
Listen carefully – picture will
emerge to give inkling of the
cause of the patients present
complaint
To put it simply!
Question
Listen
Test
Interpret
Answer
A proper approach to
information gathering
Differential diagnosis
Provisional diagnosis
Definitive diagnosis
Patients reason for seeking
treatment
Often more important than tests
performed
Dentist may find pathosis
Potential to cause current complaint
Not the pathological condition
motivating the to patient present

2. 2
Document chief complaint
Make a record of the patients
own words
Detail the patients description of
the symptoms
Medical History!!
Taken and reviewed with patient –
patient to sign the history
This will highlight the fact that this
necessary step has been undertaken
Review the history if patient not seen
for more than 1 year
Current health conditions
Diseases and disorders
Medications
Mediate the proposed treatment
Medical conditions which present
oral symptoms and signs
Conditions which mimic dental
pathosis
Examples:
1. Maxillary sinusitis
Can mimic tooth ache in maxillary
posterior teeth
2. Tumour of Central Nervous System,
pressure on the Trigeminal Nucleus,
pain in the oro-facial area
3. Myo-fascial pain
Trigger points) small foci of hyper-
excitable muscle tissue
diffuse, dull,constant ache
Mistakenly attributed to tooth or teeth
4. Trigeminal Neuralgia
Intense, sharp, shooting pain, uni-lateral
Trigger zone
Pain subsides within few mins.
Response is not proportional to the
intensity of the stimulus
See sample history sheets
“Pathways of The Pulp”
Fig. 1-1
Fig. 1-3

3. 3
Recording the results of Tests
Pre-printed forms may be useful
See “Pathways of The Pulp”
Fig. 1-3
History of the present dental
complaint
Recent dental treatment
What treatment
Which tooth/teeth
Past dental treatment
History of present dental problem
When started
How long present
Clinician’s Questioning
Once the patient has given
their perception of the problem
This questioning should direct
the interchange
Questions to Ask
?????????????
?????????????
Localization
Put finger on or tap offending tooth
Very helpful
Can narrow the search
Symptoms may not be well localized
This presents more of a challenge
Commencement
When did symptoms first occur
Patient may remember an
initiating event
E.g. recent dental treatment,
trauma biting a hard object)

4. 4
Intensity
Ask patients to rate pain on a scale of 1 –
10 with 10 being most severe
Uncomfortable sensation to cold or an
annoying pain when chewing may rate as
3 – 4
Unable to sleep with constant throbbing
pain may rate a 10
Provocation
What elicits the pain?
Cold
Hot
Chewing (upon application of pressure
or release)
Touching (tongue, finger, toothbrush)
Spontaneously
Relieved by
Cold
Non-prescription analgesics
e.g. Panadol, Nurofen, Aspirin
Of particular interest are the anti-
inflammatory pain medications
Duration – Is it?
Relieved immediately –removal of
stimulus
Lasting minutes or hours
Intermittent – spontaneous pain that
will continue for hours but remit for
variable periods and commence
again unstimulated
Extraoral Examination
1. Visual
Facial asymmetry
Loss of definition of philtrum of
upper lip or naso-labial fold
Swelling – head, face, neck
Redness
2. Palpation – Facial swelling
Diffuse
Firm
Fluctuant
Localized
Lymph nodes
Cervical, Sub-mandibular
Uni-lateral, Bi-lateral (medical
condition?)

5. 5
Facial swelling
Diffuse facial
swelling
Localized
facial swelling
Examples:
Uni-lateral facial swelling, firm
tender lymph nodes
Likely infection
Localized infection has spread into
surrounding tissues – now a
systemic problem
A diffuse facial swelling is generally
of endo. origin. Rare with Perio.
abscess
Loss of definition of philtrum of upper
lip
Incisor endo. involvement
Loss of definition of naso-labial fold
Canine involvement
Fluctuant swelling anterior palate
Upper lateral incisor or first pre-
molar
Fluctuant swelling posterior palate
Palatal roots upper molars
Intra-oral Examination
1. Swelling
Visualized
Palpated
Diffuse, localized, firm, fluctuant
May be present in:
Attached gingiva
Alveolar mucosa
Muco-buccal fold
Sub-lingual
Intra-oral swelling
Localized intra-
oral swelling,
upper buccal
sulcus
Fluctuant
swelling, anterior
palate
2. Erythema
3. Sinus formation
Can occur through:
Attached gingiva
Mucosa
Furcation
Perio. ligament (gingival crevice)

6. 6
Sinus Tracts
Drainage of inflammatory exudate from
endo. infection
Exits via Stoma
Stoma may be extra-oral or intra-oral
Sinus tract may be lined by epithelium (not
often) generally lined by granulation tissue
Intra-oral sinus
Attached gingiva
Resolution of sinus tracts
This will generally occur with
appropriate and adequate endo.
treatment
Failure to heal
Further investigation
Other aetiological factors?
Misdiagnosis?
Examples:
Swelling in the muco-buccal fold
Upper molar teeth with buccal root
apices inferior to the attachment of
muscle in that region
Lower molar teeth – buccal root apices
superior to the muscle attachment
Infections associated with lower
molars and pre-molars
Root apices above the level of mylo-hyoid
Exiting to lingual
Tongue elevated and swelling bi-lateral
(no midline division of sub-lingual space)
Post. Max. and Mand. Teeth –
infection can extend into tonsilar &
para-pharyngeal areas
Potentially life-threatening
Mandibular incisors may
involve the sub-mental and
sub-mandibular spaces
Infection exits above mylo-hyoid
attachment (sub-mental space)
Infection exits inferior to mylo-
hyoid (sub-mandibular space)

7. 7
Extra-oral sinus stoma
Involvement of sub-mental
region
Other intra-oral exams
1. Palpation - Alveolar hard
tissues
Swelling of soft tissues overlying the bony
processes
Expansion of the buccal and lingual cortical
plates (unlikely to be of endodontic origin)
Patient sensitivity during this part of the
exam
2. Percussion
Patient c/o sensitivity or
pain on mastication
Such a sign may be elicited
by percussion
A measure of inflammation
of the apical perio.
ligament
Inflammation of the Periodontal
Ligament
Possible causes:
Physical trauma
Occlusal trauma
Perio disease
An extension of endodontic
inflammation/infection to involve the
apical periodontium
Proprioception
Proprioceptors provide the sensory
input derived from mastication,
percussion and other forms of
pressure on a tooth
There are few, if any, in the pulp
Difficult to localize pain in the early stages
of pulp pathosis?
Prevalent in the ligament
With peri-apical ligament involvement
Tooth more identifiable by percussion
Diagnostic Tests

8. 8
Three primary purposes of tests
1. Reproduce symptoms
2. Localize synptoms
3. Assess severity
Psycho-social issues
Exaggeration/understatement
When performing tests
Inform the patient
Reduces anxiety
Enhancnes the diagnostic
quality of the response
Conducting tests
Test a contra-lateral tooth first
Test adjacent teeth next (that are more likely to
give a normal response)
Test the suspect tooth last
Ask patient to compare the response from
suspect tooth to that from normal tooth
Ask if the response is painful
Ask how long the pain lasts
Technique for percussion
Test first by tapping with gloved finger
nail
If no discernable result, use mirror
handle very lightly
Occlusally first
No response then test buccally and
lingually
Positive response then repeat to
confirm
Percussion Test Mobility
Degrees of mobility
1° - greater than normal
2° - less than 1mm
3° - greater than 1mm with or without vertical
mobility
Not a test of vitality
Indicator of compromised periodontal
attachment apparatus

9. 9
Mobility Test
Two
instrument
handles
Differential diagnosis –
Mobility
Acute physical trauma
Occlusal trauma – Bruxism or other para-
functional habits
Advanced periodontal disease
Root fracture
Rapid Orthodontic movement
Extension of pulp pathosis i.e. acutely
infected, non-vital teeth (acute abscess) –
often mobile. Endo. treatment will reverse
this situation
Perio examination
How to differentiate perio. condition
from a bony defect of endodontic origin
Endo. defects
Isolated, narrow opening, vertical defect.
(Can be associated with a vertical crack)
Endo lesions may exhibit furcation
bone loss
Furcation defects - perio, endo, or
combined
Thermal Pulp tests
If patient c/o sens. to cold then test
with cold
Record
No response
Normal (WNL)
Intensified (Moderate , Extreme)
Lingering
Cold Test Method
1,1-1,2 Tetra-fluoro Ethane Spray
Largish cotton pellet (make your own)
Apply to mid-facial of teeth

10. 10
Isolate and dry teeth
As for percussion inform patient
Test contra-lateral teeth
Test adjacent teeth
Test suspect tooth amongst teeth expected
to give a normal response
Instruct patient not to try to figure out which
tooth you are testing rather to tell you
“ what they feel”
Offer three options
1. Cold
2. Nothing
3. Sensitivity or pain
Heat Test Method
Patient c/o sensitivity to hot food
test with both hot and cold
Isolate and dry teeth
Lubricate teeth surfaces with
petroleum jelley
Use White gutta percha stick and
heat in flame
Apply to mid-facial area of teeth
Adopt the same procedures as for
other tests using ‘control’ teeth
Heat Test
Spontaneous pain
A tooth that is responsive to hot is
often responsible for episodes of
spontaneous or continuous pain
Often relieved by cold stimulus
e.g. cold liquids or ice pack
Pain relieved by cold

11. 11
Electric Pulp Tests
Cold and electric test provide a fairly
reliable indicator of vitality
BUT – A molar with only one vital root will
sometimes give + response to cold which
may be a heightened response
Electric test only gives indication of
presence of any viable nerve tissue
Most accurate – NO RESPONSE to any
amount of current – necrotic pulp
Electric pulp test unit
Probe
Patient
completes
circuit by
touching
metal probe
handle
Method
Isolate, dry teeth
Test contra-lateral tooth to obtain base-line
level of expected response (number on the
dial of the tester unit)
This will familiarise patient with the
sensation
Test suspect tooth twice
Use toothpaste as electrolyte to conduct
current to tooth
Apply probe to incisal 1/3 or facial aspect of
post. teeth
Application of the probe
Tooth paste
as electrolyte
If little exposed tooth
Crown and bridge work then look for
any exposed tooth
Use probe/explorer and tooth paste
and touch tester probe to the explorer
Cracked Tooth
Patient will often complain of pain on
chewing
The diagnostic feature of this pain is that it
is more noticeable when the pressure is
released
Specially designed crack testers are
available – “Tooth Sleuth”

12. 12
Tooth Sleuth
Place on
cusp tips
Pressure applied
by opposing teeth
Individual cusps can be
tested
Transillumination
Prepared by Lea Foster
References
Pathways of the Pulp 9th Ed. Cohen,
Hargreaves
Endodontic Therapy 6th Ed. Weine
Principles and Practice of Endodontics
Walton, Torebinejad
Harty’s Endodontics in Clinical
Practice Pitt Ford
Colour Atlas of Endodontics Willaim T
Johnson