Asallam Alekum Dr. Gaurav Garg, Lecturer College of Dentistry, Al Zulfi 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 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. 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. • 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. Thorough clinical examination Relevant investigations / diagnostic tests 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. 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. Chief complaint is the best starting point for a correct diagnosis PAIN is one of the most common chief complaints encountered 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. 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 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 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. 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 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 The clinician should look for: Facial asymmetry Localized swellings Lymphadenopathy Changes in color, bruises/ scars, similar signs of disease, trauma etc. Begins with a general evaluation of Occlusion The lips Cheeks Vestibules Tongue Mucosa Teeth Check for any abnormality Evaluation of the “3 C’s” : Color Contour Consistency of hard and soft tissues. 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). 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. Positive response is indicative of periodontitis which could be due to: Teeth undergoing rapid orthodontic movement. High points in recent restorations. Lateral periodontal abscess. Partial/total Pulpal necrosis. Negative response may be seen in cases of Chronic periapical inflammation Usually * Dull note- Signifies abscess formation. * Sharp note- denotes Inflammation. * Metallic note- Ankylosis. 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. 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. 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. 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 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 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). Ice Stick CO2 snow A response to cold indicates a vital pulp regardless of whether it is normal or abnormal. 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. 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). 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. 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. Cannot be used on patients having cardiac pace maker. Some E.P.T equipments are very expensive. 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. 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. Laser Doppler flowmetery Pulse Oximetery 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. 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. Light from a fiberoptic is applied from the buccal surface to illuminate the tooth to detect the fractured lines when present Tooth Slooth 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. 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. 3. Have a patient chew a disclosing tablet after taking out the filling in the suspected fractured tooth. * The line will be stained. 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. Provides information on the extent of caries in to the pulp No. of root canals and accessories The course & shape of the canals Length of the root Calcifications Resorptions PDL status Nature of periapical area & alveolar bone Root fractures (mainly horizontal) Differentiation of pathosis Location of perforations Post obturation evaluation Evaluate healing after RCT Medico legal records 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 Xeroradiography Radiovisiography (RVG) Cone beam computerized tomography (CBCT) Magnetic Resonance Imaging (MRI) Ultrasound imaging 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)