2. CONTENTS
Introduction
Diagnosis
Diagnostic method
Medical history
Drugs & medication history
Dental history
Subjective symptoms
Clinical observations
Clinical tests
3. Introduction
Thorough knowledge of other sciences
Diagnosis & Treatment planning
Pain of non odontogenic origin
Accurate database:
Medical & dental history
Clinical examination & relevant tests
Making & interpreting appropriate
radiographs
4. Diagnosis
‘The art and science of detecting
deviations from health and the cause and
nature thereof’
Differential diagnosis: ‘The process of
identifying a condition by comparing the
symptoms of all (or other) pathologic
process that may produce signs and
symptoms ’
Glossary of endodontic terms. 7th ed. Chicago: American
Association of Endodontists;2003
5. Diagnosis
Inability to test/ image the tissue directly
Indirect interpretation of response to
stimuli
Determine teeth free of disease rather
than diseased
Newton et al. JOE- Volume 35, Number 12, December 2009
6. Diagnostic method
METHODS
Pulp testing
Palpation
Percussion
DIAGNOSTIC APPROACHES
Bite test
Test cavity
Staining/ Transillumination
Selective anesthesia
Radiography
Dental history/
Medical history
Evaluation of pain
signs/ symptoms
Newton et al. JOE- Volume 35, Number 12, December 2009
7. Surgical Sieve
Pitt Ford & Rhodes. Endodontics- Problem solving in Clinical Practice
• Biographical
details
• Medical history
• Chief complaint
• History of present
complaint
• Dental history
• Social history
• Extraoral
examination
• Intraoral
examination
• Special tests
• Radiographs
• Diagnosis
• Treatment plan
8. s
A sample form used in diagnosis and treatment planning. (Adapted
from Krell K, Walton R: Odontalgia: diagnosing pulpal, periapical, and
periodontal pain. In Clark J, editor: Clinical dentistry, Philadelphia,
1987, Harper & Row.)
9. Medical history
Treatment: harmonious with general
health
Impact of the patient’s health on the
dental operating team
Alterations in the usual course of
treatment
Name & contact of physician
10. Rheumatic fever
Potential for SBE after bacteremia
Antibiotic premedication:
Artificial heart valves: Same antibiotic
coverage: rheumatic fever
Pulp
extirpation
Filing beyond
the apex
Rubber dam
placement
Initial
appointment/
Surgical
appointment
Possibilty of
going past
the apex
Periapical
lesion
11. Coronary Artery disease
Physician consultation: anticoagulant
Non surgical treatment preferred
Mild / moderate analgesics
Brief recess: more than one tooth- single
appointment
Substernal pain: dressing placed &
treatment terminated; referred to
physician
12. Hypertension
Injection of L/A solutions < 30sec/ml
Warm anesthetic solutions: few minutes
before injection
Tranquil mood created- minimal mention
of complications & failures
Hypnotic premedication: consultation
with physician
13. Hypertension
Avoid G/A & no more than 3 anesthetic
carpules
Morning appointments preferred
Night time premedication with early
appointments
Total appointment time not > 1 hour
Terminate when patient is stressed
14. Diabetes
Retarded healing: postop radiographs
Antibiotics: Infection/ surgery
1yearPre op 6 months 2 years1.5 years 3 years
15. Diabetes
Alteration in blood glucose levels:
physician consultation
Epinephrine avoided: Increase in blood
glucose levels & tissue sloughs post
surgery
Levonordefrin
Barbiturates & sedatives cautiously used
17. Hepatitis
Resistant to normal sterilization
Intracanal instruments: discarded after
use
Avoid drugs detoxified in the liver:
Halothane,Erythromycin
Cautious- Paracetamol
18. Blood diseases
Internal bleeding: L/A administration
Avoid injections: necrotic pulp
Vital pulp:
First appt.
•Access to the
cavity
•Dressing
Second appt
•A week later
•Fixed pulpal
tissue removed
•Dressing
replaced
Process
continued: vital
tissue removed
Canals enlarged
& filled
19. Blood diseases
Rubber dam: Notches- labial & lingual
surfaces
Gingival bleeding: do not treatment
without systemic diagnosis
Infectious mononucleosis:
Avoided in acute stage
• Pain
• Exacerbations
• Exaggerated
response to
drugs
20. Joint
replacement
prostheses
Bacteremia
Antibiotic
coverage
Painful joint after
procedure:
orthopedic
surgeon consulted
Longer than usual:
desirable results
Hypersensitivity states:
drugs only when
absolutely indicated
Avoid new/ unusual
drugs
HIV: transmission
avoided- proper
asepsis
Other serious
Diseases
21. Recent change in weight
Weight loss
Dieting
Loss of appetite
Systemic diseases
Weight gain
Psychogenic reasons
Hormonal
disturbances
Pregnancy
Protect exposed
tooth surfaces after
endodontic therapy
Salt & water
retention
22. Psychologic problems
Physical problems: tendency towards
anxiety
Patients on Tranquilizers/ antidepressants
Converted a
psychologic
condition to
physical problem
Severe fears &
anxieties –
treatment difficult
• No relief with treatment
• Pulpal problem
suspected: suspicious
oral conditions
• Friendly and firm
• Instruments: out of sight
• Informative booklets
• Smooth & painless initial
visit
23. Others
Hyperthyrodism
No epinephrine
Increase sedative if needed
Ulcers
Avoid aspirin & if on antacids- avoid
tetracycline
Use Penicillin V if needed
Alcoholic
Cautious with sedatives
Aspirin avoided
24. Drugs & Medication therapy
Physical condition & effects of
medications
Adverse reactions
Questionnaire format
Unaware of Drug’s contents : Mosby’s
Drug Consult/ physician
History of allergy: minimum inter
appointment time & well monitored
28. Dental history
Patient’s objective for treatment- clear
Appreciation for dental treatment
Experiences with previous dentist
Pain
relief
Check
up
Oral
systemic
relation
CosmeticsMasticatory
inefficiency
29. Dental history
Chief complaint & its history
When was it last restored?
Pulp capping/ Pulpotomy/ large
restoration in the same
Sharp blow/ accident
Swelling/ gum boil
Drainage
30. Subjective symptoms
Is the pain still present?
What type? (Sharp/ dull)
Throbbing?
Intermittent/ Continuous?
Aggravated by: cold, heat, pressure,
mastication, lying down, sweet, sour?
How long does it last?
35. Intraoral examination
Crown discoloration: non vital pulp,
removal of discolored dentin, use of
chlorinated soda
Deep carious lesions/ fractures: visual
examination & probing
36. Percussion test
Simple, but useful
Inflammatory condition of the apical
periodontium
First clinical indications of apical
periodontitis
37. Percussion test
Symptomatic apical periodontitis: more
sensitive
Pulpal diseases: not reveled unless apical
periodontium is involved
Periodontal/ endodontic etiology,
occlusal trauma, combination with
marginal periodontitis
Horizontal percussion
38. Percussion test
Firm digital pressure/ handle of instrument
like mouth mirror: tap in a vertical
direction
Patient bite on Tooth Slooth/ Cotton swab
Several teeth repeatedly
Random order
39. Palpation
Vestibular region: apical region of the root
tips
Tenderness, swelling, fluctuation,
hardness, crepitation
Tip of index finger
Usefulness increase
with skill &
clinical experience
40. Mobility
Moving in a buccal- lingual direction
Index finger on the lingual surface &
lateral force applied with instrument
handle from buccal surface
Using two fingers
41. Mobility
Miller’s index:
Class 1- First distinguishable sign of
greater- than- normal movement
Class 2- Movement of the crown as much
as 1mm in any direction
Class 3- Movement of the crown more
than 1 mm in any direction and/or vertical
depression/ rotation of the crown in its
socket
42. Periodontal probing
Endodontic & periodontic lesions mimic
each other concurrently
Record probing depths: periodontal
health & prognosis
Entire circumference probed
46. Dye staining
Dye penetrates fracture line
Demonstrates fractures
Apply – internal surfaces of cavity
preparation/ access opening
Leave it in place for a week
Iodine/ methylene blue dye
47. Dye staining
3 methods:
Remove restoration:
Direct revealing of fracture line
Dye incorporated into ZOE
mixture & placed
Patient chews on disclosing tablet
Bessner & Ferrigno. Practical guide to Endodontics
48. Bite test
Wooden stick- opposing
teeth
Tooth slooth
Patient bites down & pain elicited
upon release
Rubber dam sheet- cracked cusp
flexes
49. Pulp tests
Major & essential part of diagnostic
process
Reproduce patients symptoms, diagnose
diseased tooth & disease
2 independent diagnostic test results
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
51. Pulp sensibility tests
Pulp nerve fibers respond – external
stimulus
Thermal/ Electrical / Direct dentine
stimulation
Do not indicate the health status &
unreliable responses
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
52. Pulp sensibility tests
No indication of vitality: intact vasculature
Correlation between test results &
necrotic pulps only*
Assess whether necrotic or not & does
not quantify the degree of disease
Useful : identifying diseased tooth
*Seltzer et al.1963, Tyldesley & Mumford 1970, Dummer et al, 1980
53. Pulp sensibility tests
Preferred sequence:
Tests repeated after 1’ recovery time
Thermal tests: no method to assess how
responsive the tooth is or to compare with
previous result
EPT: numerical display- not essentially
reproducible
Disease free
contralateral
teeth
Opposing
teeth
Presumably
healthy teeth-
same
quadrant
Most
suspicious
tooth
54. Rationale of the tests
Sharp, non lingering pain- application of
thermal stimulation: normal
A - 25% stimulus required to activate C
fibers*
*Virtanen 1985, Hargreaves & Goodis 2002
55. Thermal tests- Rationale
Sensory response: not by temperature
changes in receptors
Hydrodynamic movement of fluid:
dentinal tubules- A fibers
Cold- faster A fibers: sharp localized
pain
Heat- slower C fibers: dull long lasting pain
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
56. Electric Pulp Test - Rationale
Current sufficient to overcome the
resistance of enamel & dentine- stimulate
A fibers
Sensation felt with gradually increasing
level of current: pulp responsive/ partially
alive
*Ionic shift in tubules local
depolarization action potential
Pantera et al. 1993
57. EPT- Rationale
A fibers: brief sharp sensation/ tingling
*No blood flow- pulp becomes anoxic &
A fibers cease to function
*Pitt Ford & Patel 2004
58. Indications
1.Pain in the trigeminal area; referred pain
2. Periodical monitoring of teeth after
trauma
1-8 weeks lapse before normal response
EPT: reliable after trauma**
*No response Response : Recovery
Repetitious response :Healthy pulp
Response No response: Degeneration
No response persistent: Necrotic pulp
**Ingle et al 2002,*Bhaskar & Rappaport 1973
59. Indications
3. Assessment of pulpal health before
restorative procedures
potential prosthetic abutment
4. Pulp preservation procedures & extensive
restorations
5. Differentiate periapical radiolucencies
from normal anatomical structures & non
odontogenic lesions
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
60. Indications
6. Predict potential anesthetic problems &
evaluation of analgesics
Cold test: assess pulpal anesthesia
Preoperative pulp-test performed
Traditional parameters verified
Retested with the same test
Prepared for treatment & level of
anesthesia screened
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
63. Limitations
1. Subjective; measure only nerve supply
2. Thermal tests: not effective in substantial
secondary dentine formation
3. Unreliability of tests: Immature apices,
traumatic injuries, more subjectivity in the
young
4. No correlation with the histologic status
(Contrasting results: Hill, 1986)
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
64. Limitations
5. Difficult to administer & inconclusive in
children
6. Weaker response- aged pulp
7. Extensive restorations, pulp recession,
pulp calcification
8. Lack of reproducibility
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
65. Interpretation- Diagnosis
Immediacy, intensity & duration of
response
Outcome: never certain
No particular response- unique to specific
pathologic states
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
66. Clinically Normal pulp
Mild to moderate transient response to
cold & electrical stimuli
Response subsides in few seconds on
removal of stimulus
Do not usually respond to heat tests
67. Reversible pulpitis
Thermal stimuli (cold)- sharp pain
Subsides as soon as the stimulus is
removed/ in few seconds
68. Irreversible pulpitis
Thermal changes (cold): sharp pain , dull
prolonged ache- last upto an hour or so
Valuable: stimulus as reported by patient
applied & pain reproduced & assessed
EPT: not of value
69. Pulp necrosis
Histological state not determined
Significant relation between lack of
response & pulp necrosis
No response with EPTs & thermal tests
No indication of infection expected from
these
70. Pulp necrobiosis
Difficult to diagnose
History : pulpitis
Pulp tests: necrosis
Vague response to EPTs, cold tests
71. Periapical conditions
Acute apical periodontitis
Maybe associated with pulpitis
Pulp status assessed before treatment
Acute apical abscess
Negative
Lateral periodontal abscess
Positive
Chronic apical periodontitis
Sequel of infected canal system
72. False responses
False negative results: Normal pulps that do
not respond to tests
Calcification: no response to cold; may
respond to high value of current in EPT
Premedication
Recent trauma
Immature apex
RCT teeth: not expected to respond
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
74. False responses
False positive results: Necrotic pulps
responding to tests
Conduction of current to adjacent
gingival & periodontal tissues (avoided with
reasonable current strength & proper techniques)
Moist gangrene, partially necrotic tissue,
infected pulp
Breakdown products of localized necrosis
75. False responses
Calcified tooth structure conducting to
tissue apical to an area of necrosis
Current conducted to adjacent teeth
through metallic restorations (avoided by
rubber dam / celluloid strips between teeth)
Inflamed pulp tissue in one canal of a
multirooted teeth with other canals &
chamber necrotic
Anxious/ young patient
76. False responses
More common with EPT than cold test
EPTs: all teeth; cold tests: multirooted
teeth
EPT: rare false negative, if more than one
surface used
Cold test: sometimes, only cervical area
responds
77. Value of diagnostic tests
Precision: ‘Tendency of repeated
measurements on the same sample to
yield the same result’
Variability: Lack of precision
Accuracy: The extent to which a test
correctly classifies patient’s response
Sensitivity: The ability of the test to detect
the disease in patients who actually have
the disease
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
78. Value of diagnostic tests
Specificity: The ability of a test to detect
the absence of a result
Positive predictive value: The probability
that a positive test result actually
represents a disease positive tooth
Negative predictive value: The probability
that a tooth with a negative test result is
actually free from the disease
79. Value of diagnostic tests
Heat: relatively high sensibility; but least
accurate being the least specific
Cold test: more accurate than EPT
80. Thermal tests
Often inappropriately referred to as
‘Vitality tests’
More reliable than EPT
Inexpensive & easy-to- use equipment
Patient’s pain reproduced
82. Damage to hard & soft tissues
of the tooth
Heat test: more potential to injure
Tissue freezing: -100c for 5-20’
Intracellular ice crystal formation &
ischemic necrosis following vascular
injuries
-220c lowered pulp temperature to 110c:
caused no damage (Langeland et al,
1969)
83. Damage to hard & soft tissues
of the tooth
Conflicting reports: Dry ice inducing
enamel cracks
Delayed cold transfer process: Cold
stimulus applied to necrotic pulps under a
bridge- felt by adjacent tooth
‘Film boiling’/ ‘ Leidenfrost phenomenon’:
Insulating layer of CO2 gas around dry
ice, if it falls into mouth
85. Cold tests
Freezing water- hypodermic needles’
plastic cover/ L/A cartridges
Held using gauze
Cervical (Ruddle 2002),or middle (Cohen
& Hargreaves 2006),exposed metal
surface
Quickly move back & forth
86. Cold tests
Begin with most posterior tooth
Cotton pellet placed just distal to the
tooth
Contact with adjacent gingiva or nearby
teeth: false responses
87. Cold tests
Refrigerant sprays
Convenient & easiest to use
Ranks just behind dry ice
Dichlorodifluoromethane (DDM)
Tetrafluoroethane (TFE)
Propane butane mixture (PBM)
-20oC to -50oC
88. Cold tests
DDM: Freon-12
Compressed spray: Endo-Ice (-50oC)
DDM- production prohibited due to
environmental concerns
Greater decrease in temperature than
dry ice & ethyl chloride
Saturated cotton pellet:
Multiple teeth : less effeicienty tested
89. Cold tests
TFE: Green Endo-Ice (-26oC)
No ozone depletion potenial
Easy to use & rapid results
Sprayed onto cotton pellet & applied to
middle third facial surface
5s or until pain
Equivalent to dry ice & even in restored
teeth
91. Cold tests
Carbon di oxide snow/ Dry Ice
Charles Thilorier -1835
Dentistry: Back -1936
Apparatus modified by Obwegser &
Steinhauser 1963: pencil like form
-78oC; -56oC direct application
Rapid response: <2 s
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
92. Cold tests
Mechanism:
PDJ temperature reduced to <2oC
Hydrodynamic theory
Enamel expansion / contraction & acts as
temperature transfer medium
(Linsuwanont et al 2007)
93. Cold tests
Technique
CO2 released into special tube inside
plexiglass container: snow
Compacted with a plugger: pencil/ stick
Middle third of the facial surface of
crown: 2-5seconds or until pain
94. Cold tests
Advantages
Accurate, reliable, consistent, fast &
uncomplicated
1-2 minutes- without isolation
Does not affect adjacent teeth
Intense reproducible response
Greater accuracy than EPT
95. Cold tests
Full coverage restorations
More reliable after trauma
Under splinted abutments
No false positive in necrosis
Sustained lingering response: early
puplpitis
Fixed orthodontic treatment
96. Cold tests
Disadvantages
Not effective with calcified pulps
More expensive than ethyl chloride/ ice
sticks
More dependable results than ethyl
chloride/ ice (Fuss et al 1986, Andreasen
1976)
97. Cold tests
Ethyl chloride spray
Chloroethane (-12.3oC)
Colorless, flammable gas
Skin refrigerant, mild topical anesthetic
CNS depressant
Better than EPTs & heated GP
Not used: less effective than dry ice/ DDM
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
98. Cold tests
Cold water bath
Tooth/ group of teeth : isolated with
rubber dam
Iced water syringed onto tooth
Effective: simultaneous bathing of entire
crown
Effective with full coverage restorations
Better than ice sticks & no
armamentarium than rubber dam
Time consuming
99. Heat tests
Heat: fluid expansion- A fibers
Inflamed pulp: C-fibers; lasting response
Acutely inflamed/ partially necrotic pulp
Low diagnostic accuracy- not used as
single method
100. Heat tests
Heated GP ( Grossman’s method)
Warmed sticks of GP (120-140oC)
Dry tooth surfaces & surrounding areas
with cotton rolls
Iight coating of petroleum jelly
GP stick warmed over flame
till glistening
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
101. Heat tests
Difficult to control temperature
Concerns of damage to healthy pulp :
not with <5 s application
(Rickoff et al 1988)
Reproducible results not obtained
Lack of response in bulkier teeth
Less consistent stimulus
Limited value: posterior teeth & under
splints , temporary crowns
102. Heat tests
Warmed hand instruments
Popular, not very reliable & poorly
assessed method
Heated over a flame, held close to
buccal surface; without actually touching
Not reproducible
Difficult to control temperature & safety
problems
103. Heat tests
Electrical heat sources
Touch ‘N Heat/ System B- 150oC
Inserts: Hot Pup Test Tip
Continuous heat mode- intensity set
Tooth surface lubricated
Jafarzadeh & Abbott. IEJ, 43, 738-762, 2010
Castelucci. Endodontics Vol.1
105. Heat tests
Hot water bath
Similar to cold water bath
Temperature gradually increased
Begin with most posterior and proceed
until positive response
Greater thermal change
PFM crowns
Time consuming & patient cooperation
106. Remember..
Inform patient of the nature of tests
Hand signals
Stimulus removed after 5-6 s
Refractory period after cold test
Cervical aspect (Petyers eta 1994, Ruddle
2002)
middle third of buccal/ palatal aspect
(Cohen & Hargreaves 2006)
107. Incisal- anterior & incisal aspect of
mesiobuccal cusp: posterior (Trope &
Debelian 2005)
Ideally be tested on all surfaces
Several adjacent, contralateral &
opposing teeth tested
Individual perception
Should not bias
108. Electrical pulp tests
Direct stimulation of pulp nerve fibers
Unreliable: necrotic & disintegrating pulp
tissue leaves electrolytes in pulp space
Adequate stimulation, appropriate
technique, careful interpretation
AC or DC; Pulsating DC: 5-15ms best
nerve stimulation
Rate of current increase, strength duration
& frequency
109. Electrical pulp tests
Benchtop style digital EPT
Handheld style digital style EPT
Handheld style analog EPT
110. EPT
Monopolar/ Unipolar and Bipolar
Mains power connection & Batteries
Mid-1950’s: Bipolar- one electrode to the
other through tooth or one handheld
Monopolar: anode on the lip & cathode
on the tooth
Comparative studies: conflicting results
111. EPT & Histology
No correlation between positive EPT &
histological status*
Presence of sensory fibers that can
respond to electrical stimulus
Quantification or comparison of
responses- not conclusive
Cannot assess vitality
Negative response- necrosis
Reynolds 1966, Mumford 1967b, Matthews et al 1974b, Cooley &
Robinson 1980
112. Technique of use
Technique sensitive
Removal of supragingival calculus
Exterior surface dried & rubber dam
placed
Insulation of proximal restorations
Probe checked on skin- ensure current
flow
113. Circuit completed
Electrode coated with suitable medium
Middle third of facial surface
Direct contact necessary: small tip on
restored teeth
Rheostat: 1-10, 1-15, 1-80
Slowly increased: more accurate
114. Procedure explained
Tingling/ warm/stinging/ full/hot
Shift tip position: if no response
Tested 2 0r 3 times: ensure consistency
Testing switched off / changing order;
eliminates bias & anxiety driven responses
115. Full porcelain/ gold crowns
Cavity prepared through restoration
without L/A until dentin
If no response: EPT probe on dentin
Rubber dam piece: insulate tip from
metal
Highly different response: control tooth
116. Circuit completion
Use without rubber gloves
Lip clip: lose retentiveness & reliable
contact
Touch the probe handle with finger: gives
patient control
Modify EPT with metal rod
117. Roll down dentist’s gloves: contact with
wrist & patient’s face
Custom made patient held contact
device
Stabilization groove cut on the probe
engaged by current conducting sleeve:
not recommended
118. Variations in reading/ False
response
Failure to complete
the circuit
Equipment
problems
Probe placement
Interface media
Patient related factors
Tooth characteristics
Restored teeth
Dentition
Supporting tissues
Apex maturation
Repeated trials
Psychological state
Physiological state
119. False positive response
Necrotic pulp responds to testing.
Stimulation of adjacent teeth/
attachment apparatus
The response of vital tissue in multirooted
tooth with pulp necrosis in one or more
canals
Patient interpretation: subjectivity
William T. Johnson. Colour Atlas of Endodontics
120. False negative response
Vital pulp that does not respond to
stimulation
Inadequate contact with the stimulus
Tooth calcification
Immature apical development
Traumatic injury
Subjective nature of the tests
Elderly patients – regressive neural changes
Analgesics for pain
Traumatic injury
121. Limitations of EPT
No information on
health status/ integrity
Unreliable for immature
teeth
Not suitable with full
coverage restorations
Chances of ventricular
fibrillation
122. Test cavity
Non localized, acute diffuse radiating
pain
Definitive diagnosis: impossible
Cavity prepared in the tooth: concealed
position without anesthesia
Patient apprised of what to expect & how
to respond
123. Test cavity
Response: cavity preparation stopped &
restored again
No response: endodontic access cavity
continued
Low speed handpiece & small bur
recommended
Full crown restorations & margins
contacting gingival tissue
124. Test cavity
Young teeth: immature roots- invasive
nature questioned
Unreliable; response even in necrotic pulp
Response unreliable: anxiety
Invasive & irreversible
No further information than thermal & EPT
Not justified in modern practice
125. Laser Doppler Flowmetry
Jafarzadeh .IEJ, 42, 476-
490,2009
Optical measuring
method- number &
velocity of particles
conveyed by a
fluid flow to be
measured
Laser light is
transmitted to the
pulp by means of a
fiber optic probe
126. Laser doppler
flowmetry
Scattered light from the moving RBCs in
the circulation will be frequency-shifted,
while those from the static tissues remain
unshifted.
Reflected light composed of Doppler
shifted and unshifted light is returned to
photodetectors
Detected & processed -signal measure of
the blood flow in the dental pulp
Jafarzadeh .IEJ, 42, 476-490,2009
127. Laser doppler
flowmetry
Not useful in teeth with crowns
and large restorations
Detect only the coronal blood flow of the
pulp, which may not relate to the actual
blood flow on the linear scale.
Advantages:
Painless diagnosis as compared to
thermal & electric pulp tests
Diagnosis of immature or traumatized
teeth
128. Pulse Oximetry
Effective, objective oxygen saturation
monitoring technique - intravenous
anesthesia
Consistently determined the level of
blood oxygen saturation of the pulp- pulp
vitality testing
Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009
129. Pulse Oximetry
Correlation between pulp and systemic
oxygen saturation readings (Schnettler
and Wallace1991)- definitive pulp vitality
tester
Biox 3740 Oximeter (Kahan et al 1996)
Custom-made Pulse
Oximeter sensor holder
(Gopikrishna et al 2006)
Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
130. Pulse Oximetry
Probe containing two LEDs: red light-
660 nm & infrared light (900–940 nm)
Measures absorption of oxygenated and
deoxygenated Hb
Received by a photodetector diode
connected to a microprocessor.
Relationship between the pulsatile change in
the absorption of red light & infrared light :
assessed by the oximeter + known absorption
curves for oxygenated and deoxygenated
hemoglobin,
Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009
132. Pulse Oximetry
70%- 100% accuracy
Inverse correlation between saturation
values & EPT readings (Radhakrishnan et
al 2002)
More sensitive & specific compared to
cold tests & EPT (Gopikrishna et al 2007)
Jafarzadeh & Rosenberg. JOE Vol 35, No. 3, March 2009
133. Dual Wavelength
Spectrophotometry
Method independent of a pulsatile
circulation
Measures oxygenation changes in the
capillary bed rather than in the supply
vessels
Detects the presence or absence of
oxygenated blood at 760 nm and 850nm.
Advantage: Uses visible light that is filtered
and guided to the tooth by fibreoptics
Divya et al.Contemporary Diagnostic AIDS in Endodontics”. Journal of Evolution of Medical
and Dental Sciences 2014; Vol. 3, Issue 06, February 10
134.
135. Ultraviolet light/Fiberoptic
Fluorescent Spectrometry
Fluorescence
Vital teeth fluoresce normally; necrotic &
RCT teeth do not –Foreman
Lighting in the operatory fully suppressed
Patient & staff wear suitable protective
goggles
Fluorescence from the pulp -substantially
lower than the healthy and decayed
dentin fluorescence.
Healthy and decayed dentin patterns
differentiated
Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
136. Photoplethysmography
Optical measurement technique : blood
volume changes in the microvascular bed
of tissue.
Light source to illuminate the tissue & a
photodetector to measure the small
variations in light intensity associated with
changes in perfusion
Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
137. Anesthetic test
L/A: painful area
Block/ infiltration/ intraosseous
Vague location of pain
Non odontogenic pain:Myocardial
infarction
Differentiating between arches
PDL- identify source of pulpal pain.
140. Tooth surface temperature
Fanibunda: pulp circulation maintains
tooth temperature
Cholesteric crystals- 10% solution in
chlorinated hydrocarbon solvent(Howell
et al)- non vital: lower temperature
Thermistor: vital & RCT teeth- with and
without gold crowns (Banes & Hammond)
Consistent (Stoops & Scott)
Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
141. Tooth surface temperature
Electronic thermography: Infrared sensor,
control unit, thermal image computer,
software, color monitor, printer
Differences in deep & superficial areas-
not sensitive
Hughes Probeye 4300 thermal video
system: sensitive to measure 0.1oc
Adjunct to other diagnostic tests
142. Patient temperature
Baseline temperature: follwed up
Patient is improving/ worsening
>1000oF : systemic response to infection
143. Ultrasound
Compliment conventional radiography
High resolution, 3D images- inner
macrostructure of the tooth
A transducer (a crystal containing probe),
a coupling agent & software
Detect cracks in a simulated human tooth
Detect vertical root fractures – vital &
nonvital teeth
Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
144. Ultrasonic Doppler Imaging
Blood circulation detected
Distinguish vital teeth from root- filled
teeth: blood flow parameters, waveform,
sound
Promising tool- traumatically injured teeth
Power Doppler associated with color
Doppler – improved sensitivity to low flow
rates
Yoon et al. JOE- Volume 36, No.3, March 2010
Vital tooth
Non vital tooth
145. Optical Reflection Vitalometry
Preliminary report-1997 (Oikarinen et al)
Noninvasive method
The pulse of the pulp/oral mucosa.
Yet to be clinically accepted &
commercially available.
Tyagi et al.Saudi Endodontic Journal • May-Aug 2012 • Vol 2 • Issue 2
146. Evaluation of Sensibility Tests
Thermal test: Endo Ice & EPT- evaluated
Endo Ice- 0.904 accuracy & EPT- 0.75
Age group 21-50 & vital teeth: more
accurate response to cold test
Jespersen et al. JOE- Volume 40, No.3, March 2014
147. RADIOGRAPHY-Little value : assess
pulp status
Presence & extent
of carious lesions
Vital pulp therapy
Calcifications
Resorptions
Periradicular
radiolucencies
Tracing fistulous
tracts
Thickness of PDL
Periodontal
disease
Root & pulp space
anatomy
Previous RCT
153. References
Endodontic therapy – Weine
Endodntics6- Ingle et al
Cohen’s sPathways of the Pulp- 10th ed
Color Atlas of Endodontics- William T.
Johnson
Endodontics- Problem solving in Clinical
practice- Pitt Ford
Practical Endodontics- A clinical guide.
Bessner & Ferrigno
154. Pocket Atlas of Endodontics- Beer
H. Jafarzadeh & P. V. Abbott. Review of
pulp sensibility tests. Part I: general
information and thermal tests. IEJ, 43, 738-
762, 2010
Yoon et al. JOE- Volume 36, No.3, March
2010
Jespersen et al. JOE- Volume 40, No.3,
March 2014