Asallam Alekum
Dr. Gaurav Garg, Lecturer
College of Dentistry, Al Zulfi
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Diagnosis is a process of determining the nature of
a disease.
very important for proper treatment.
Differential diagnosis is the process of
differentiating between similar diseases.
For correct differential diagnosis:
Proper knowledge of the disease
Skill and Art on how to apply proper diagnostic
methods
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As stated by Grossman, are phenomenon or
signs of a departure from the normal, and are
indicative of an illness.
Types:
1. Subjective Symptoms are those which are
experienced and reported to the clinician by the
patient.
2. Objective Symptoms are those, which are
obtained by the clinician through various tests.
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Lingering tooth sensitivity to cold liquids.
Lingering tooth sensitivity to hot liquids.
Tooth sensitivity to sweets.
Tooth pain to biting pressure.
Tooth pain that is referred from a tooth to another
area, such as the neck, temple, or the ear.
Spontaneous toothache, such as that experienced
while reading a magazine, watching television, etc.
Constant or intermittent tooth pain.
Severe tooth pain.
Throbbing tooth pain.
Tooth pain that may occur in response to postural
changes, such as when going from a standing to a
reclining position.
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Good case history:
Chief complaint
Past medical history
Past dental history
Also includes vital signs, history of presenting illness.
It is essential to gather collective information
regarding signs, symptoms, and history for a successful
outcome of any treatment procedure.
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Thorough clinical examination
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Relevant investigations / diagnostic tests
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Side effects of medications:
Stomatitis, xerostomia, petechiae, ecchymosis, lichenoid
lesions & mucosal & gingival bleeding.
Lymphoma or Tuberculous involvement of cervical &
submandibular lymph nodes
Immunocompromised & patients with uncontrolled
Diabetes
Patients with iron deficiency anaemia, pernicious anemia &
leukemia frequently exhibits paraesthesia of oral soft tissues
complicating making a diagnosis when other dental
pathosis is also present in the same area of the oral cavity.
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Multiple myeloma can result in unexplained mobility of
teeth.
Radiation therapy to head & neck region can result in
increased sensitivity of teeth & osteoradionecrosis
Trigeminal neuralgia, referred pain from cardiac angina,
and multiple sclerosis can also mimic dental pain.
Acute maxillary Sinusitis- a condition that may mimics
tooth pain in maxillary posterior quadrant. In this situation
the teeth in the quadrant will be extremely sensitive to cold
& percussion, thus mimicking the signs & symptoms of
Pulpitis.
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Chief complaint is the best starting point for a
correct diagnosis
PAIN is one of the most common chief
complaints encountered
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In order to attain a detailed knowledge regarding pain,
following questions may be necessary:
1. Type of pain :
Grossman has stated Pulpal pain to be of the following two
varieties :
Sharp, piercing and lancinating -- a painful response usually
associated with the excitation of the A-DELTA nerve fibers.
This pain usually reflects REVERSIBLE state.
Dull, borinq, gnawing and excruciating-- a painful response
usually associated with the excitation of C-nerve fibers.
Usually reflects an irreversible state of pulpitis.
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2. Duration of pain:
When the pain is of a shorter duration (1
minute)-Reversible Pulpitis - Excellent chance
of recovery without the need for endodontic
treatment
Whereas when the pain is of a longer duration,
it is considered to be Irreversible Pulpitis
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3. Localization of pain:
Sharp piercing pain can usually be localized and
responds to cold
Dull pain usually referred / spread over a larger area
responds more abnormally to heat
Patients may report that their dental pain is
exacerbated while lying down or bending over
This occurs because of the increase in blood pressure to
the head, which therefore increases the pressure on the
confined pulp
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4. Factors which provoke/ relieve pain:
Response to a provoking factor (e.g. on
mastication) indicates pulp vitality, but
stimulation causing extended severe pain suggests
irreversible pulpitis.
Pain provoked with cold usually suggest
reversible pulpitis & with hot usually suggest
irreversible pulpitis
Thus pain, which is recorded as the complaint is
considered to conclude an acute or chronic,
reversible or irreversible condition of the pulp.
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Characterized by pain which is of a :Shorter duration
Localized
May be piercing/ lancinating in nature
More responsive to cold than heat
Caused by a specific irritant & disappears as
soon as it is removed
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Abnormal dental pain, which responds to heat
Which occurs on changing the position of the
head, awakening the patient from sleep
Dull pain of Longer duration, which occurs
during mastication in a Cariously exposed
tooth
History
Slight sensitivity or
occlusal pain
Constant or intermittent pain
Pain
Momentary &
immediate, sharp in
nature & quickly
disappears thereafter
Continuous, Delayed onset,
throbbing, persists for minutes to
hours after removal of stimulus
Location of pain
May be localized & is
not reffered
Pain is not localized. If it is
localized, its only after periapical
involvement. Pain is reffered.
Lying down
No difference
Pain increases
Thermal test
Responds
Marked & prolonged
E.P.T.
Early response
Early, delayed or mixed response
Percussion
Negative
Negative in early stages. Later
positive when periapex is
involved
Radiography
Negative
May show widening of PDL
space
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The clinician should
look for:
Facial asymmetry
Localized swellings
Lymphadenopathy
Changes in color,
bruises/ scars,
similar signs of
disease, trauma etc.
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Begins with a general evaluation of
Occlusion
The lips
Cheeks
Vestibules
Tongue
Mucosa
Teeth
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Check for any abnormality
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Evaluation of the “3 C’s” :
Color
Contour
Consistency of hard and soft
tissues.
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Use fingertip with a light digital pressure
to examine tissue consistency and pain
response.
The importance of this test other than as
an aid in locating the swelling over an
involved tooth, is in determining the
following:
Whether the tissue is fluctuant and
enlarged sufficiently for incision and
drainage.
The presence, intensity and location of
pain.
The presence and location of
Adenopathy
The presence of bony Crepitus (in case of
cyst).
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Can be done with finger or with the handle of
the instrument (a mouth mirror etc )
Instruct patient to raise his/ her hand the tooth
feels “TENDER”, “DIFFERENT” or painful on
percussion.
The teeth should be percussed in a random
fashion so that the patient cannot “anticipate”
when the tooth will be percussed
Percussion is done in both vertical and
horizontal directions.
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Positive response is indicative of periodontitis which could be due
to:
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Teeth undergoing rapid orthodontic movement.
High points in recent restorations.
Lateral periodontal abscess.
Partial/total Pulpal necrosis.
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Negative response may be seen in cases of
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Chronic periapical inflammation
Usually
* Dull note- Signifies abscess formation.
* Sharp note- denotes Inflammation.
* Metallic note- Ankylosis.
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To evaluate the integrity of the
attachment apparatus
surrounding the tooth.
Moving the involved tooth
laterally in socket using handles
of two instruments or more
preferably using two index
fingers.
The test for Depressibility is
similar and is performed by
applying pressure in an apical
direction on the occlusal/incisal
aspect of tooth and observing
vertical movement if any.
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According to MILLER:
0 - Non mobile/ mobility within physiologic
limits.
1 - Mobility within range of 0-0.5mm.
2 - Mobility within range of 0.5-1.5mm with lateral
movements.
3 - Mobility more than 1.5 mm with lateral
movements and can be
Intruded/depressed into the socket.
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Periodontal examination- a
must
Check for periodontal pockets &
Furcation involvement.
Thermal and electric pulp tests
must be performed along with
periodontal examination to
distinguish between disease of
Pulpal and Periodontal origin.
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The heat test can be performed using different techniques
such as:
1. Hot air
2. Hot water
3. A hot burnisher
4. Hot gutta-percha
5. Hot compound
6. Polishing of crown with a rubber cup
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Inform the patient
Isolation of the quadrant to be tested, test the adjacent teeth
first (avoid metallic restorations & exposed root surfaces).
The preferred temperature for performing a heat test
(according to Cohen) is 65.5ºC or 150F.
An abnormal response to a heat test exhibits presence of a
pulpal or peri apical disorder requiring endodontic
treatment.
A heat test does not confirm vitality.
The response could be localized, diffused or even referred to
a different site
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Isolating the quadrant with the tooth
to be tested.
Cold application can be performed in
any of the following ways viz.
A stream of cold air from a 3-way
syringe directed against the crown of
previously dried tooth.
Use of ethyl chloride spray (which
evaporates rapidly ) absorbing heat
and cooling the tooth surface (-55ºC).
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Ice Stick
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CO2 snow
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A response to cold indicates a vital
pulp regardless of whether it is
normal or abnormal.
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There are four possible reactions, that the patient may
experience,
1. No response - may be non vital or vital but giving a
false- negative response due to excessive calcifications,
immature apex, recent trauma, patient medication etc.
2. Painful response- which subsides when stimulus is
removed from the tooth- Reversible pulpitis.
3. Moderate, transient response- Normal.
4. Painful response- which lingers after removal of
stimulus- Irreversible Pulpitis.
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Historically, the E.P. tester has been used in dentistry
as early as 1867.
Designed to stimulate a response by electrical
excitation of the neural elements within the pulp.
Does not provide any information regarding the
vascular supply to the tooth.
Considered advantageous when compared with the
thermal tests since the quantitative readings are
obtained which can be compared with that of a later
test (when conducted).
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Test should be first described to the patient .
Teeth to be tested should be isolated with
cotton rolls, saliva ejector and air dried.
Check the E.P. tester for proper functioning.
Apply an electrolyte on the tooth surface
(Nicholls-colloidal graphite, Grossman-tooth
paste).
Avoid contact of the electrolyte or electrode
with any restorations or the adjacent gingival
tissue as this could lead to a false response.
Retract the patient’s cheek or lip with free
hand, away from the tooth electrode.
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Intensity of stimulus is comfortable to the patients.
The digital display of many E.P.Testers provide
instant, easy and reliable information.
In some E.P. Testers, a red indicator light flashes
on and off when maximum stimulus is reached.
Gives a quantitative reading and can be compared
with the normal reading of control tooth.
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Cannot be used on patients having cardiac pace maker.
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Some E.P.T equipments are very expensive.
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E.P.T is not useful for recently erupted teeth with immature
apex. This may be because the relationship between the
odontoblasts and the nerve fibers of the pulp has yet to
develop.
Recently traumatized teeth cannot be tested.
No indication is given regarding state of the vascular supply
which would give a more reliable measure of the vitality of
the pulp.
Readings from posterior teeth with partially vital pulps may
be misleading.
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Reasons for a False Negative Response:
Patient heavily pre-medicated with analgesics, narcotics,
alcohol,
tranquilizers.
Inadequate contact with enamel.
Recently traumatized tooth.
Excessive calcification in the canal.
Recently erupted tooth with an immature apex. This
according to Nicholls, may be because the relationship
between the odontoblasts and nerve fibers of the pulp has
yet to develop.
The results obtained through the E.P. T conducted should
not be thoroughly relied upon and should be co-related with
other vitality tests such as the thermal tests etc.
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Laser Doppler flowmetery
Pulse Oximetery
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Restricted to patients who are in pain at the time of the test and
when the usual tests have failed to help identify or localize the
offending tooth.
The objective is to anesthetize a single tooth at a time until the
pain disappears and is localized to specific tooth.
infiltrate the posterior most tooth in the suspected zone.
If pain persists anesthetize the next tooth mesial to it and continue
to do so until the pain disappears.
If the source of pain cannot be differentiated ie. ,maxillary /
mandibular, then mandibular block is implemented.
further localization of the affected tooth is done by an
intraligamentary injection, once the anesthetic has spent itself.
one of the last resorts in localizing the offending tooth.
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last resort
The cavity is prepared by drilling through DEJ of an
unanesthetized tooth at a slow speed and without a water coolant.
Sensitivity and pain elicited by the patient is an indication of the
pulp vitality.
A Sedative cement is then 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 may be continued until the pulp chamber is reached
and if the pulp is noticed to be necrotic, routine endodontic
treatment could be performed.
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Light from a fiberoptic
is applied from the
buccal surface to
illuminate the tooth to
detect the fractured
lines when present
Tooth Slooth
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An orangewood
stick is placed on
the
occiusal/incisal
aspect (on each
cusp in case of
posteriors) of the
tooth and the
patient is asked to
bite.
To identify the
fractured tooth
/cracked tooth
syndrome.
1. Remove the filling from the suspected tooth and
place 2% Iodine in the cavity preparation.
* The iodine stains the fracture line dark.
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2. Mix a dye with zinc-oxide eugenol and place it in the
cavity preparation after filling has been removed.
* The dye will seep out and color the fracture line.
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3. Have a patient chew a disclosing tablet after taking
out the filling in the suspected fractured tooth.
* The line will be stained.
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Can localize the
endodontic lesion to the
specific tooth.
Aids in the differential
diagnosis between a
periodontal and an
endodontic lesion.
Placing a gutta percha
point through the
sinus/fistula tract and
take a radiograph.
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Provides information on
the extent of caries in to
the pulp
No. of root canals and
accessories
The course & shape of the
canals
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Length of the root
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Calcifications
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Resorptions
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PDL status
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Nature of periapical
area & alveolar bone
Root fractures (mainly
horizontal)
Differentiation of
pathosis
Location of
perforations
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Post obturation
evaluation
Evaluate healing
after RCT
Medico legal
records
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State of pulpal health
can not be ascertained
Caries/ Periapical
pathology is evident
only after much
destruction(33%)
Vertical root fracture
can not be diagnosed
Bony trabculae
misinterpreted for
horizontal root fracture
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Xeroradiography
Radiovisiography (RVG)
Cone beam computerized tomography (CBCT)
Magnetic Resonance Imaging (MRI)
Ultrasound imaging
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REFERENCES:
1. COHEN-Pathways of the Pulp (Ninth Edition)
2. GROSSMAN- Endodontjc Practice (Eleventh Edition)
3. INGLE-Endodontjcs (Fourth Edition)
4. WEINE-Endodontic Therapy (Fifth Edition)
5. Technical equipment for assessment of dental pulp status(Endodontic
Topics 2004, 7, 2–13).
6. Pulpal diagnosis (Endodontic Topics 2003, 5, 12–25).
7. Classification, diagnosis and clinical manifestations of apical
periodontitis(Endodontic Topics 2004, 8, 36–54)