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1. DIAGNOSTIC PROCEDURES
Introduction
Correct treatment begins with a correct diagnosis. Arriving at a right
diagnosis requires knowledge, skill and art.
• The dictionary defines diagnosis as “the art of identifying a disease
from its signs and symptoms.
• Symptoms are units of information sought in clinical diagnosis.
 Symptoms are defined as phenomena / signs of a departure from the
normal and indicative of illness.
Symptoms can be classified accordingly:
• Subjective symptoms: are those experienced and reported to the
clinician by the patient.
• Objective symptoms: are those ascertained by the clinician through
various tests.
Many diseases have similar symptoms. Hence the clinician must be
astute in determining the correct diagnosis.
Differential Diagnosis:
 This technique distinguishes one disease from several other similar
disorders by identifying their differences.
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2.  Diagnosis by exclusion on the other hand, eliminates all possible
diseases under consideration, until one remaining disease correctly
explains the patients symptoms.
Thus the criteria for on accurate clinical diagnosis includes:
 a good case history
 a thorough clinical examination
 relevant investigations / diagnostic tests
Medical History:
 Even though there are virtually no systemic contraindicatios to
endodontic therapy (except uncontrolled diabetes or a very recent
myocardial infarction), a recent and succinct, 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 require antibiotic prophylaxis before clinical
examination because, of systemic conditions like:
 Heart value replacement
 A history of rheumatic fever
 Advanced AIDS
2

3.  In case of patients who daily take anticoagulant medication may
need to have the dose reduced or dosing suspended, especially in case of a
periodontal examination.
 When patients report being infected with communicable diseases
such as AIDS, tuberculosis, Hepatitis B, dentists and staff must use
protective barriers.
 The clinician must also know what drugs the patient is taking so
that adverse drug reactions can be avoided.
 Patients 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 interests of the patient, Doctor and Staff.
Dental History:
After completing, the medical history, the clinician should develop the
dental history.
 The purpose of a dental history is to create a record of the chief
complaint, the signs and symptoms the patient reports, when the problem
began and what the patient can discern that improves / worsens the
condition.
 The most effective way for the clinician to gather this important
information is to ask the patient pertinent questions regarding the chief
complaint and listen carefully and sensitively to the patient responses.
 Because dental pain frequently is the result of a diseased pulp, it
is one of the most common complaints.
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4.  Whatever the reason, the patients chief complaint is the best
starting point for a correct diagnosis.
Subjective Symptom: As mentioned before PAIN is a subjective symptom.
 Judicious questioning of the pain can aid the
diagnostician in developing a tentative diagnosis quickly.
One should ask the patient the following:
 the kind / type of pain
 Location of the pain
 Duration of the pain
 What causes the pain
 What alleviates it
 Whether it is referred to another site or not
Type / Kind of pain: Generally pulpal pain is described by the patient in one of
the 2 ways.
(a) Sharp, piercing and lancinating – due to the excition of the “A-delta”
nerve fibres (myelinated principal sensory fibres) in the pulp. This pain
may reflect on a reversible state of pulpitis.
(b) Dull, boring, growing and excruciating pain: due to excitation and
shower rate of transmission of the “C” nerve fibres (unmyelinated
fibres).
 This pain usually reflects on IRREVERSIBLE STATE OF
PULPITIS.
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5. Duration of pain:
 At times pulpal pain lasts only as long as an irritant
is present.
 At other times, it lasts for minutes to hours.
 In case of Acute reversible pulpitis.
 Pain – short duration – disappears soon after
removal of the stimulus.
 Sharp, lancinating and piercing
 Usually localized
 Is more responsive to cold than to heat.
 In case of irreversible pulpitis,
 Pain – persists even after removal of the stimulus or irritant.
 Diffuse.
 Longer duration.
 Responds abnormally to heat than to cold.
Localization of pain:
Pain is localized when the patient can point to spot a specific tooth or
site with assurance and speed when asked to do so.
 Usually short, piercing, lancinating pain is easy to localize and responds
promptly to cold.
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6.  When the pain is diffuse, it relates to a dental pain that is dull, boring
and gnawing.
 This pain can also be referred to other sites.
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, for eg. be ipsilaterally referred to the preauricular area, or down
the neck or up the temporal area.
 In these instances the source of extraorally refereed pain almost
invariably is a posterior tooth.
Patients may report that their dental pain is exacerbated by lying down
or bending over.
 This occurs because of the increase in blood pressure to the head, which
increases the pressure on the confined pulp.
 Abnormal dental pain caused by heat usually requires endodontic
treatment.
 Pain that occurs on changing the position of the head, awakens the
patient from sleep, or occurs during mastication of food in a cariously
exposed tooth usually indicates a need for treatment.
Acute Reversible Pulpitis Irreversible Pulpitis
6

7. Pain:
 Sharp,
laminating, piercing.
 Short
duration – disappears soon after
removal of the stimulus.
 More
responsive to cold.
 Usually
localized.
 Dull,
boring, growing excruciating pain
longer duration.
 Persists
even after removal of the stimulus /
irritant.
 Responds
abnormally to heat them to cold.
 Diffuse.
Objective Symptoms:
Objective symptoms are determined by tests and observations
performed by the clinician.
These tests are as follows: Commonly used tests
1. Visual and tactile inspection
2. Percussion
3. Palpation
4. Mobility and depressibility
5. Radiographs
6. Thermal tests
7. Electric pulp test
8. Periodontal examination
9. Test cavity
10. Anesthesia test
11. Occlusal pressure test
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8. 12. Gutta-percha point tracing
13. Transillumination
14. Staining
Special Methods:
1. Xero – radiography
2. Pulse – oximetry
3. Laser – Doppler flowmetry
4. Computerized Tomography
5. Digital subtraction radiography
6. M.R.I.
7. R.V.G.
8. Computerized expert system
1. Visual and Tectile Inspection: This is one of the most simplest clinical
tests.
 Too often, it is done only causally during examination, and as a
result, much essential information is lost inadvertently.
 A thorough visual, tactile examination relies on checking the
“3Cs” - Colour, Contour, Consistency.
In case of soft tissues: such as gingiva – any deviation from the healthy, pink
colour is readily recognized when inflammation is present.
Contour: a change in contour occurs when there is swelling.
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9. Consistency: a change in consistency from normal, healthy firm tissue to that
of a soft, fluctuant or spongy tissue indicates a pathologic condition.
In case of Hard tissues: even the hard tissues i.e. the teeth should be visually
examined using the “3 Cs”.
Colour: a normal appearing crown has a lifelike translucency and sparkle that
is missing in pulpless teeth.
• Teeth that are discoloured, opaque and less lifelike in appearance
should be carefully evaluated.
Because the pulp may already be inflammed, degenerated or necrotic.
• Not all the discoloured teeth will require endodontic treatment.
 Staining maybe caused by old amalgam restorations, root canal
filling materials and medicaments, or systemic medication, such as
tetracycline staining.
 Many discolourations, however, are the result of disease
commonly associated with nectrotic and gangrenous pulps, internal or
external resorption, carious exposure.
Contour: crown contours should be examined.
Causes for changes in the crown contour could be:
 Fractures
 Wear facets
 Restorations
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10.  The clinician should be prepared to evaluate
the possible effects of such changes on the pulp.
Consistency: of the hard tissue relates to the presence of caries and internal or
external resorption.
Technique: the technique of visual and tactile examination is simple.
 It can be done with one’s fingers, an explorer and the periodontal probe.
 The patients teeth and periodontium should be examined in good light
under dry conditions.
For Example: a sinus tract (fistula) might escape detection if it is covered by
saliva or an interproximal cavity may escape notice if it is filled with food.
 Loss of translucency, slight colour changes and cracks may not be
apparent in poor light (in such cases, a trasilluminator may aid in
detecting enamel Cracks / Crown #s)
 Visual examination should also include the soft tissues adjacent to the
involved tooth, for detection of swelling.
 The crown of the tooth should be carefully evaluated, to determine
whether it can be restored properly after completion of endodontic
treatment.
 Finally, a rapid survey of the entire mouth should be made, to ascertain
whether the tooth requiring treatment is a strategic tooth.
3. Percussion:
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11.  In percussion, the crown of a tooth is tapped with the tip of a finger or
with an instrument.
 A painful response to percussion denotes inflammation of the
periodontal membrane.
 Although percussion is a simple method of testing, it may be
misleading if used alone.
 In performing the test, several teeth are percussed in a random order, to
eliminate bias on the part of the patient.
 Initially a suspect tooth should be tapped very gently, since the
periodontal membrane maybe extremely tender. If there is no response
a sharp tap is given.
 One should change the direction of the blow from the vertical occlusal
to the buccal or lingual surfaces of the crown and strike separate cusps
in a different order.
 It must be born in mind that tenderness to percussion does not
necessarily denote pulpal disease.
 A tooth with a healthy pulp may develop on acute apical periodontitis
from a blow or premature occlusal contact.
or an acute periodontitis maybe the sequel to food packing between two
teeth.
The absence of a response to percussion is quite possible when there is
chronic periapical inflammation.
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12. If a metallic instrument is used, the sound produced by percussing a
tooth with periapical disease is sometimes obviously duller than that given by
a tooth with an intact periapex.
4. Palpation: in this simple test, light pressure is applied with the fingertip, to
examine tissue consistency and pain response.
• Although simple, it is an important test
• Its value lies in locating the swelling over an
involved tooth and determining the following:
i. whether the tissue is fluctuant and enlarged
sufficiently for incision and drainage.
ii. the presence, intensity and location of pain
iii. the presence and location of adenopathy
iv. the presence of bone crepitus.
When palpation is used to determine adenopathy, it is advisable to
exercise caution when palpating the lymph nodes, in the presence of an acute
infection, to avoid the possible spread of infection through the lymphatic
vessels.
Diagnostically:
 When posterior teeth are infected, the submaxillary lymph modes
become involved.
 When anterior teeth are involved, the submental lymph nodes become
involved.
12

13. Tenderness over the root apex of a tooth indicates inflammation of the
periodontal membrane. But this can also result from other causes other than
pulpal diseases.
 Excluding absess formation associated with periodontal disease,
swelling of the mucosa over the root apex of a tooth denotes partial or
complete necrosis of the pulp.
 When the infection is confined to the pulp and has not progressed into
the periodontium, palpation is not diagnostic.
 Palpation, percussion, mobility and depressibility test the integrity of
the attachment apparatus i.e. the periodontal ligament and bone, and are
not diagnostic when the disease is confined within the pulpcavity of a
tooth.
 In short, palpation, mobility and depressibility are tests of the
periodontium rather than of the pulp.
5. Mobility – Depressibility testing:
The mobility test is used evaluate the integrity of the attachment
apparatus surrounding the tooth.
 The test consists of moving a tooth laterally in its sockets by using the
fingers or preferably, the handles of two instruments.
 The objective of this is to determine whether the tooth is firmly/ loosely
attached to its alveolus.
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14.  The amount of movement is indicative of the condition of the
periodontium. The greater the movement, the poorer the periodontal
status.
Similarly, the test depressibility consists of moving a tooth vertically in
its socket.
 This test may be done with the fingers or with an instrument.
 When depressibility exists, the chance of retaining the tooth ranges
from poor to hopeless.
Classification of mobility: (According to Grossman)
i) First degree mobility: is barely discernible movement.
ii) Second degree mobility: is a horizontal movement of 1 mm or less.
iii) Third degree: is a horizontal movement of greater than 1mm, often
accompanied by a vertical component of mobility. The pressure
exerted by the purulent exudates of an acute apical abcess may
cause some mobility of a tooth. In this situation the tooth may
quickly stabilize after drainage is established and occlusion is
adusted.
Additional causes for tooth mobility:
1. Advanced periodontal disease.
2. Horizontal root fracture in the middle and coronal third.
3. Chronic bruxism / clenching.
Note on Mobilometers:
14

15. These are electronic devices / gadgets which aid in determining
tooth mobility.
The apparatus essentially consists of two electrodes or prongs which
hold the facial and lingual surface of the teeth. The degree of mobility tested is
then reflected as a numerical reading either on the instrument itself or on an
attached computer screen.
Radiographs:
The radiograph is one of the most important clinical tools in making
a diagnosis.
 But some clinicians rely exclusively on radiographs to arrive at a
diagnosis which can lead to major errors in diagnosis and treatment.
Because the radiograph is a two dimensional image of a 3-dimensional
object, misinterpretation is a constant risk.
 To use radiographs properly, the clinician must have the knowledge and
skill necessary to interpret them correctly.
 A thorough understanding is required of the underlying normal or
anomalous anatomy and the changes that can occur due to aging
trauma, disease and healing.
 It is important that radiographs be of excellent quality.
 To produce an excellent radiograph one must master the necessary
skills:
1. Proper placement of the film in the patient’s mouth.
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16. 2. Correct angulation of the cone in relation to the film and oral structures
(to prevent distortion of the anatomic images).
3. Correct exposure time – so the images are recorded with identifiable
contrasts.
4. Proper developing technique.
Radiographs can contain information on:
1. Presence of caries that may involve or may threaten to involve the pulp.
2. The number course, shape, length and width of the root canals.
3. the presence of calcified material in the pulp chamber or root canal.
4. the resorption of dentin originating within the root canal internal
resorption or from the root surface (external resorption).
5. Calcification or obliteration of the pulp cavity.
6. Thickening of the periodontal ligament.
7. Resorption of cementum.
8. Nature and Extent of periapical and alveolar bone destruction.
9. Root Fracture.
When posterior teeth are being investigated, a bite wing film provides
an excellent supplement for finding the extent of carious destuction, the depths
of restoration, the presence of pulp caps or pulpotomies and dens evaginatus or
invaginatus.
16

17. Root fractures: These could be difficult to detect on a radio graph, especially
vertical root fractures which can be identified only in advanced cases of root
resorption.
Horizontal fractures maybe confused radiographically with linear
patterns of bone trabecule.
The two can be differentiated by noting that the lines of bone trabeculae
extend beyond the border of the root while root fractures often cause
thickening of the periodontal ligament.
17

18. Difference between internal and external resorption:
Differentiation between internal and external resorption maybe made
radiographically:
1. The lesion of internal resorption usually has sharp smooth margins that
can be clearly defined. However, it need not be symmetrical.
2. The pulp “disappears” into the lesion not extending through (i.e. the
shadow of the pulp) the lesion in its regular shape.
Radiographic misinterpretation:
In some instances two or more exposures are necessary to check out
detail from more than one horizontal angle. This is especially in the case of the
mental foramen – this foramen maybe directly superimposed over the apex of
the mandibular premolars for example.
 The nasopalatine foramen also maybe superimposed on the apex of the
maxillary central incisors.
 These foramina are actually some distance from the apices of these
teeth.
 To find out whether it is a foramen or truly a periapical lesion one must
change the horizontal angle of the cone of the x-ray machine to the
mesial / distal during separate exposures.
 If the radiolucent arc is actually a lesion associated with the periapex
than its shadow will remain “attached” to the root end despite of a
mesial or distal shift in separate films.
18

19. Lesions within the tooth observable by radiographs:
a. Pulp death in a developing tooth is readily apparent because the
root ceases to develop.
b. Pulp stones, inflammation.
c. Internal resorption seen following traumatic injury.
Lesions outside the tooth observable on radiographs:
Some of the most common occurrences seen radiographically on the out
side of the root of the tooth are –
a. Widening of periodontal space occurring due to
 Acute apical periodontitis.
 Acute apical abscess
 Occlusal trauma.
b. Changes associated with chronic periapical abscess.
c. External root resorption.
In case of external root resorption: lesion has ragged margins and
shadow of the pulp “passes through” the lesion unaltered.
RADIOGRAPH ANGULAR – PERIRADICULAR LESIONS
Most often the following features are seen:
 Widened periodontal ligament space
 Inflammatory apical root resorption
19

20.  Most often associated with pulp necrosis and
infection.
Other conditions where one can notice a windened PDL space are:
 Acute apical periodontitis
 A beginning acute apical abscess
 Acute pulpitis (occasionally)
Radiographic changes as sequelae to pulp necrosis
The commonly observed changes are:
a) Chronic apical periodontitis – a well circumscribed osseous lesion
 Radiolucent area varying in size from a few mms to a cm or
larger in size
 Border / bony perimeter maybe radiopaque.
 Do not always occurs at the periapex / occasionally seen on the
lateral surface of the root in association with an accessory canal.
b) Chronic apical abscess:
 Larger, more diffuse and irregular radiolucent
lesion.
c) Apical cyst: may develop from a chronic abscess.
In this case lesion appears – more circumscribed, more like a
“granuloma” in appearance.
20

21.  It also moves roots of teeth laterally.
NATKIN has postulated that the larger the lesion the more apt it is to be a
cyst.
A number of pathologic changes in and near the alveolar process maybe
mistaken for periradicular lesions of pulpal origin. They are:
I. Lesions of non endodontic origin:
1. Globulomaxillary cyst – inverted pear shaped.
2. Midline palatal cyst – occurs in the midline.
3. Cyst of the nasopalatine canal or foramen – occurs mainly in the
palatine process.
II. Periodontal lesions: maybe mistaken for periradicular ones.
⇒ The periodontal probe and pulp tester are invaluable in
determining the origin of the lesion.
⇒ Another method is to place a silver or gutta percha point in the
periodontal pocket and take a radiograph.
III.Cementoblastoma: common errors in diagnosis center around the lesions
of cementoblastoma particularly during stage I when radiolucency is so
apparent.
(Once it begins to calcify into a selerotic lesion, little doubt should exist
about the nature of the lesion).
7. Themal testing:
21

22. One of the most common symptoms associated with a symptomatic
inflammed pulp is pain induced by hot or cold stimulation.
 Hot and cold tests are valuable diagnostic aids.
• According to Grossman, although both are tests of sensitivity they are
dissimilar and are conducted for different diagnostic reasons.
• A response to cold indicates a vital pulp, regardless of whether that pulp is
normal and abnormal.
• A heat test is not a test of pulp vitality. An abnormal response to heat
usually indicates the presence of a pulpal or periapical disorder requiring
endodontic treatment.
 Another diagnostic difference pointed out by Grossman is that
when a reaction to cold occurs the patient can quickly point out
to the painful tooth.
 Whereas in a heat test, the response could be localized or
diffused or even referred to a different site.
The results of the thermal test should be correlated with the results of
other tests to ensure validity.
Technique of performing thermal tests:
 Before testing, the patient should be told what tests are going to be
performed and why.
 Additionally, the patient should be given some idea of what to expect.
22

23.  The tests should be first performed on teeth which are to be used as
controls i.e. corresponding (if found) on the opposite side of the same
arch. Contralateral teeth can also be used as controls.
 By doing so, the patient gets an idea of how the tests will feel.
 The dentist should also inform the patient how to respond when a
sensation is experienced.
For Eg: The patient should be instructed to raise a hand as soon as any
sensation is felt.
The heat or cold test (even EPT) tests are performed by placing the stimuli on:
Anterior teeth: labial (enamel) surface of the incisal third of the crown.
Posterior teeth: Occluso Buccal surface.
However, placing the stimulus on exposed dentin should be avoided –
because an accelerated or exagerrated response is likely.
Also the stimulus should not be applied against restorations unless
unavailable.
Non-metallic restorations: Poor conductors
tests gives a delayed response or no response
Metallic-restorations: Good conductors
 This can result in response at low levels of stimulation.
 They may also cause misleading results by conducting the
stimulus to an adjoining metallic restoration in another tooth.
23

24.  This effect can be reduced by placing a celluloid strip between the
teeth.
 The teeth in the quadrant must first be isolated and then dried with 2x2
inch guaze and a saliva ejector placed.
 Cohen states that teeth should not be dried with a blast of air because
 Room temperature air might cause shock.
 Saliva might be sprayed on the clinician or the assistant.
Heat Test: The heat test can be performed using different technique that
deliver different degrees of temperature.
⇒ According to Cohen the preferred temperature is
65.5°C (150°F). But according to AHR Rowe et al in his article on
Assessment of pulpal vitality (Int End Journal 1990 V-23) temperatures
upto 150°C are necessary for conducting thermal tests on teeth which are
first smeared with Vaseline to avoid g.p. sticking to tooth.
Heat testing can be made with
 Hot air blast
 Hot water
 Hot burnisher / any instrument which can deliver
controlled temperature to the tooth
 Hot Gutta-percha
Where a gold crown is present, heat maybe applied by polishing the
crown with an Abrasive disc.
24

25. When testing with gutta-percha, it is heated over an alcohol flame until
it becomes shiny and sags, but before it begins to smoke.
Care should be taken not to place an overheated gutta percha stick or
prolonged application of the stick as it may cause a burn lesion in an otherwise
normal pulp.
A different technique is required for the application of hot water.
Method:  Isolate with rubber dam
 Tooth is immersed in “Coffee hot” water delivered from a
syringe.
(According to Cohen this is the best method for thermal testing teeth
with porcelain or full metal coverage).
Disadvantages: The response noted is limited to only the tooth which is tested.
Cold Test: For the cold testing, the teeth must remain isolated and dry.
The most common techniques for cold testing utilize,
1. A stream of cold air from a 3 way syringe directed against the crown of
a previously dried tooth.
2. Ethyl chloride spray – it is sprayed liberally on a (evaporates rapidly by
absorbing heat and cooling the tooth surface) cotton pellet and held
against the middle 3rd
of the facial surface.
The ethyle chloride technique is effective even on teeth covered with
cast metal crowns.
25

26. 3. Sticks of ice
4. Carbon dioxide snow in the form of dry ice pencil.
 This produces lower intrapulpal temperatures than other methods
(Aisberger and Peters 1981).
 Is far more effective (Ehrmann, 1973).
 Reliable even in immature teeth.
Responses to thermal tests:
The patients responses to heat and cold testing are identical because the
neural fibres in the pulp transmit only the sensation of pain (Hydrodynamic
theory – Brannstorm).
There are four possible reactions the patient may have:
1. No response – pulp maybe non vital
Or vital, but giving a false negative response because of
 Excessive calcification
 Immature apex
 Recent trauma
 Patient premedication
2. A mild to moderate transient thermal pain response.
 This is usually considered normal.
3. A strong, painful response that subsides quickly after removal of the
stimulus – this is characteristic of Reversible pulpitis.
26

27. 4. A strong, painful, response that lingers after the thermal stimulus is
removed – this indicates a symptomatic irreversible pulpitis.
Modification of technique for thermal tests:
 A modified technique for the heat and cold thermal
tests is provided by the analytical technique pulp tester
which has a hot probe tip and a cold probe tip.
The heating of the hot probe tip and cooling of the cold probe tip are
controlled separately in the membrane switch on the control panel.
8. Electric Pulp Tests: The electric pulp
tester is designed to stimulate a response by electrical excitation of the
neural elements within the pulp.
Historically, the EP tester has been used in dentistry since as early as
1867 and has evolved over the years into the present electronic digital pulp
tester.
It is a valuable tool for diagnosis because not only does it help the
clinician in determining pulp vitality but with thermal and periodontal tests it
can also aid in differentiating among radiographic signs of pulpal, periodontal
or non odontogenic cause.
• The EP test merely suggests whether the
pulp is vital or non vital.
• It does not provide any information about
the health or integrity of the pulp.
27

28. • It does not provide any information about
the vascular supply to the tooth, which is the real determinant of
vitality.
Technique:
1. Describe the test to the patient in a way that will reduce anxiety and
will eliminate a biased response. To eliminate a biased decision EPT
should first be performed on a normal healthy tooth (control), adjacent
or contra lateral. This aids in determining the patients threshold level.
2. Isolate the area of teeth to be tested with cotton rolls and a saliva ejector
and air dry all the teeth.
3. Check the electric pulp tester for function, and determine that current is
passing through the electrode.
4. Apply an electrolyte (tooth paste) on the tooth electrode and place it
against the dried enamel of the crowns’ occlusobuccal or inciso labial
surface.
 All restorations must be avoided because they may
cause a false reading.
5. Retract the patients cheek away from the tooth electrode with the free
hand. This hand contact with the patients cheek completes the electrical
circuit.
6. Turn the Rheostat slowly to introduce minimal current into the tooth
and increase the current slowly.
28

29.  Patients should be instructed to raise a hand as
soon as they begin to feel slight tingling or sensation of heat.
 Record the result according to the numeric scale on
the pulp tester.
Each tooth should be tested 2 or 3 times and the reading averaged.
Reason: The patient’s response may vary slightly (which is common) or
significantly (which suggests a false positive or negative the response).
Factors - affecting level of Response:
1. Enamel thickness: Thicker the enamel, the more delayed the response.
(Thin anterior teeth – respond faster, Broad posterior teeth – slower
response – because of greater thickness of enamel and dentin).
2. Probe placement on the tooth.
(Posterior teeth: occlusal third, anterior teeth: Incisal third – to avoid
false stimulation of gingival tissue).
3. Dentin calcification
4. Interfering restorative materials.
5. The cross sectional area of the probe tip
6. patient level of anxiety.
Advantages of E.P.T:
1. Intensity of stimulus is comfortable to the patients.
29

30. 2. The digital display of many E.P. Testors provides instant, easy and
reliable information.
3. In some E.P. testers, a red indicator light flashes on and off when
maximum stimulus is reached.
4. Gives a quantitative reading which can be compared with the normal
reading of control tooth.
Disadvantages of EPT:
1. It cannot be used on patients having cardiac pacemaker because of
potential interference with the pacemaker.
Studies by woolley and associated have shown that currents of the
magnitude of 5 to 20 milliamps are sufficient to modify normal pacemaker
function.
2. Usually cannot be used when gloves are worn.
In order to stimulate the pulp nerve fibers, the electric current must
complete a circuit. Hand contact with the patients cheek completes the circuit.
With gloved hands that connection is interrupted.
3. Some E.P. Testers are very expensive.
4. EPT is not useful on recently erupted teeth with immature apex.
Studies have shown that newly erupted teeth have more unmyelinated
axons than do mature teeth the speculation being that some of these larger
fibres may ultimately become myelinated. Since it is principally the pulpal A
fibers that respond to electric pulp testing, variability in the number of ‘A’
30

31. fibres entering the tooth offers a possible explanation to why electric pulp tests
tend to be unrealiable in young teeth.
5. Recently traumatized teeth cannot be tested.
6. The probe tip of some EPT is removable and it falls out easily.
7. No indication is given regarding the state of vascular supply which
would give a more reliable measure of the vitality of the pulp.
8. Readings from posterior teeth with partial vital pulps maybe
misleading. (because in multirooted teeth one canal may have vital pulp
tissue and other canals necrotic tissue).
False Reading: As stated, the results from the EPT could be misleading and
these could be grouped as:
A) False positive response: means the pulp is necrotic but the patient
nevertheless signals that he feels sensation.
B) False negative response: means the pulp is vital but the patient appears
unresponsive to electric pulp tests.
Main reasons for a false positive response:
1. Conductor / Electrode contact with a larger metal restoration (bridge,
class II restoration) or the gingiva allowing the current to reach the
attachment apparatus.
2. Patient anxiety.
3. Liquifaction necrosis may conduct current to the attachment apparatus
and the patient may slowly raise his/hand near the highest range.
31

32. 4. Failure to isolate and dry the teeth properly.
Main reasons for a false – negative response:
1. Patient heavily premedicated with analgesics, narcotics, alcohol or
tranquilizers.
2. Inadequate contact with the enamel.
3. Recently traumatized tooth.
4. Excessive calcification in the canal.
5. Dead batteries or forgetting to turn on the pulp tester.
6. Recently erupted tooth with an immature apex.
7. Partial necrosis (Although the pulp is still partially vital, electric pulp
testing may indicate that it is totally necrotic).
Types of pulp testers:
Two types of electric pulp tester are available
I. 1) Current is varied II. 1. Monopolar
2) Voltage is varied 2. Bipolar
The former in which current is varied is considered preferable, since a
given voltage may lead to different amounts of current due to variation in the
electrical resistance of the tissues, especially enamel.
The common commercially available testers are:
32

33. 1. Analytic technology pulp tester: Here the wave form has an output in
the form of bursts of ten high frequency pulses followed by a space.
 This is done to minimize patient discomfort.
 The EPT is turned on automatically when the probe touches the
tooth and is turned off when the tooth contact is broken (after a
delay of 15 secs).
 There is a digital display and the only control on the EPT is the
rate of increase of the stimulus.
 To complete circuit patient may touch metal handle.
2. Digilog pulp tester
3. Green wood pulp tester
4. Pelton crane pulp tester
5. Parkell pulp tester (battery operated)
Periodontal Examination:
No dental examination is complete without careful evaluation of the
teeth’s periodontal support.
 The periodontal probe should be an integral part of all
endodontic tray set ups.
 Using a periodontal probe, the clinician examines the
gingival sulcus and records the depths of all pockets.
33

34.  Multirooted teeth are carefully probed to determine whether
there is any furcation involvement.
 A lateral canal exposed to the oral cavity by periodontal
disease may become the portal of entry for toxins that cause pulpal
degeneration.
 To distinguish lesion of periodontal origin from those of
pulpal origin, thermal and electric pulp tests, along with periodontal
examination are essential.
9. Test Cavity:
This method is performed when other diagnostic methods have failed.
 It involves the slow removal of enamel and dentin to determine pulp
vitality.
 Without anesthesia and using a small round bur, the dentist removes the
dentin with a revolving high speed bur aimed directly at the pulp.
 If the pulp is vital, the patient will experience a quick sharp, pain at or
shortly beyond the dentin enamel junction.
 A sedative cement can then be placed in the prepared cavity and the
search for the cause of pain may be continued.
 On the contrary, if no pain / sensitivity is recorded, the cavity
preparation maybe continued until the pulp chamber is reached and if
the pulp is noticed to be necrotic, routine endodontic treatment could be
performed.
34

35. 10. Anesthesia test:
 In the uncommon circumstance of diffuse strong pain of vague origin,
when all other tests have failed, the Anesthesia test is performed.
 Objective: To anesthetize a single tooth at a time until the pain
disappears and is localized to a specefic tooth.
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, when the tooth has been fully anesthetized, anesthetize,
the next tooth mesial to it and continue to do so until the pain
disappears.
 If the source of pain cannot be determined whether in maxillary or
mandibular teeth, an inferior alveolar (mandibular block) infection
should be given.
 Cessation of pain naturally indicates involvement of a mandibular
tooth, and localization of the specefic tooth is done by the intraligament
injection, when the anesthetic has spent itself.
 This test is obviously a last resort and has an advantage over the “Test
cavity”, during which iatrogenic damage is possible.
11.Occlusal pressure or Biting test: A frequent patient complaint is pain on
biting or chewing.
Causes for such symptoms: - Apical periodontitis,
- Apical abscess
35

36. - Incomplete tooth fractures
 A clinical test that simulates the chief complaint is the occlusal
pressure test or biting test.
Method: Several methods exist like biting on:
 Orangewood stick
 Burlew rubber disc
 Wet cotton roll
 The oragnewood stick and Burlew rubber disc allow pinpoint testing of
individual cusp area.
 The wet cotton roll has the advantage of adapting to the occlusal
surface allowing for pressure over the entire occlusal table.
 An interesting clinical observation in patients with tooth infarctions
(“Cracked Tooth Syndrome”) is pain often experienced when biting
force is released rather than during the downward chewing motion.
12. Gutta-Percha Point Tracing:
Technique: Place a gutta percha point through the sinus / fistulous tract and
take a radiograph.
 This can localize endodontic lesion to the specific tooth.
 In addition, this test aids in the differential diagnosis between a
periodontal and an endodontic lesion.
13. Transillumination & Magnification:
36

37.  Fiberoptic lighting and chairside magnification have become
indispensable in the search for cracks, fractures and unfound canals and
obstructions in root canal therapy.
 The fact that magnification (e.g. microscopes) and trasillumination
might allow the dentist the only means of diagnosing an offending
cracked tooth is becoming an increasing reality.
14. Staining: The purpose of a staining test is isolation of a cracked tooth.
Technique: there are 3 methods to stain a tooth.
1. Remove the filling from the suspected tooth and place 2% Iodine in the
cavity preparation. The iodine stains the fracture line fracture lines can
be identified with food colouring placed on the dried occlusal surface.
 The dye solution stains the fracture line.
 The occlusal surface is cleaned with a cotton pellet lightly
moistened with 70% isopropyl alcohol.
 The alcohol washes away the food coloring on the surface, but
the colouring within the fracture line remains and becomes apparent
2. Mix a dye in zinc oxide eugenol cement and place it in the cavity
preparation after filling has been removed. The dye will seep out and
line the fracture.
3. Have patient chew a disclosing tablet after taking out the filling of the
fractured tooth. The fracture line will be stained.
SPECIAL METHODS
37

38. 1. Xeroradiography:
Xeroradiography is an imaging technique that has been proposed as an
alternative to conventional x-ray film radiography. The term xero-radiography
is derived from the greek word “xeros” which means “dry”.
Technique: The x-ray image is recorded on a photo-conductive selenium
coated plate rather than x-ray film.
Before use, the selenium plate is given a uniform electrostatic charge,
placed in a light proof plastic cassette, positioned in the mouth, exposed to x-
ray.
 The processed image is transferred onto clear adhesive tape and fixed
on to an opaque plastic base.
 The resulting image maybe viewed either as a photograph with
reflected light or as a radiograph with transmitted light from a view
box.
Advantages:
1. The radiation exposure is 1/3rd
that of the conventional x-ray film.
2. Better edge enhancement and image quality.
3. Xeroradiographs have inherently wide latitude.
i.e. it is possible to image objects having a broad range of densities in a
single exposure.
 Wide latitude also means the acceptable images can be obtained
over a relatively broad range exposure conditions.
38

39. Advantage is – it can dramatically reduce the number of exposures that have to
be repeated because of technical inadequacies.
 The height of alveolar crest is often well demonstrated, aiding in
diagnosis of periodontal disease.
 Caries maybe seen readily.
4. It produces permanent dry image for viewing in about 20 seconds.
5. The plates maybe reconditioned, recharged and used repeatedly.
39

40. 2. Pulse Oximetry:
 Tests relying on the passage of light through a tooth have been
considered as a possible means of detecting pulp vitality with greater
objectivity.
 The pulse oximeter is a non-invasive O2 saturation monitor that
provides continuous pulse rate readings.
 The liquid crystal display (LCD) gives oxygen saturation, pulse rate
and plethysmpographic wave form readings.
Concept: Pulse oximetry uses red and infrared wave length in order to
transilluminate a tissue bed and detects absorbance peaks due to pulsative
circulation.
 This information is used to calculate the pulse rate and oxygen
saturation.
 The tooth to be tested is sandwiched between a photoelectric detector
and red and infrared light emitting diodes.
This method is clearly superior to other vitality tests since it does not
rely upon sensory nerve response. (Other routine methods rely on stimulation
of a-delta nerve fibres for assessment of pulp vitality).
40

41. 3. Laser Doppler Flowmetry:
Due to the biased, false –ve and positive responses elicited through the
EPT the need for a better and more reliable method for determining pulp
vitality arose.
 A method which determined and registered the blood flow rather than
the neural response was preferred.
LDF was thus introduced first in 1972 to determine blood flow in
Retina of Rabbits – RIVA, Ross and Benedek as a non-invasine method to
measure blood flow.
 The crux of the LDF is based on the detection of movement of blood
cells in the pulpal blood vessels, with thus gives a true picture regarding
pulp vitality.
Technique: essentially consists of a laser light i.e., helium neon laser at
632.8nm.
 It is focused on the tissue under study with a fiber optic probe.
 As the light hits the various components of the tissues, it is partially
absorbed and partially back scattered.
The back scattered light has 2 components:
i) Light back-scattered from the static tissues which
has the same frequency as the light going on.
ii) The other component is the Doppler shifted light
with a different frequency.
41

42. The back scattered light is processed and an ouput signal is produced
i.e. both the unshifted an shifted light is transmitted to a detector by optical
fibres where it is charged into an electric current and processed.
The detected output signal can be fed onto an analog printer, or be rand
from a digital board.
Advantages of LDF:
1. Non-invasive.
2. Simple to apply.
3. Provides a continuous record.
4. Useful to demonstrate establishment of vitality of untreated teeth.
Disadvantages:
1. Impossible to calibrate the readings in absolute units.
2. Output may not be linearly related to blood flow.
4. Computerized Tomography:
Computed tomography was introduced in the mid 1970’s.
 Computed tomographic systems are also referred to as computed axial
tomography scanners (CAT).
 CT scanners produce digital data measuring the extent of x-ray
transmission through an object.
 This numerical information maybe transformed into a density scale and
used to generate or reconstruct a visual image.
Tachibana, has reported about the use of x-ray CT in endodontics.
42

43.  It is possible to determine the 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. Observation of structures which are difficult to visualize with
conventional x-rays.
2. Provides images for 3-dimensional image of roots, root canals and
teeth.
Disadvantages:
1. Expensive
2. Skin dose is large
3. Time consuming.
5. Digital subtraction radiography:
The progress of caries from an incipient lesion, the DEJ is often
difficult to detect.
 Likewise, the assessment of healing or expansion of the periapical
lesion after root canal therapy is a challenge therefore the subtle
changes in the density of the lesions maynot be detectable with the
naked eye.
 Subtraction radiography offers a remedy for these problems.
43

44.  It is an image enhancement method. Here, the area under focus is
clearly displayed against a neutral gray black background or it is
superimposed on the radiograph itself (i.e. the required areas are
enlarged against the entire background).
 This DSR maybe used to assess the successfulness of RCT and also
periapical lesions.
6. Radiovisuography:
RVG digitizes ionizing radiation and provides an instantaneous image
on a video monitor, thereby reducing radiation exposure by 80%.
The RVG has 3 components:
1. Radio component: consists of an hypersensitive intra oral sensor and a
conventional x-ray unit.
2. “Visio” portion: consists of a video monitor and a display processing
unit.
3. “Graphy” portion: is a high resolution video printer that provides an
instant hard copy of the screen image using the same video signal.
Advantages:
1. Elimination of X-ray film
2. Significant reduction in exposure time.
3. Instantaneous image display
The RVG system appears promising for the future of endodontics.
44

45. But, the resolution of RVG is slightly lower than that produced with
conventional film, which can however be improved through enhancement
procedures.
7. Computerized expert system:
Reported by John Firrola, the CES Viz, Comendex was used for the
diagnosis of selected pulpal pathosis i.e.
 Normal pulp
 Reversible pulpitis.
 Irreversible pulpitis (due to hyperocclusion).
 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.
- With rapid advances being made in the field of
computers one can expect more efficient programmes for endodontic
diagnosis.
Conclusion:
To conclude, I would like to say that one cannot depend solely on these
tests to arrive at a diagnosis.
- As mentioned before, the clinicians knowledge,
skill and art combined with these diagnostic tests will help one to make the
right diagnosis.
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