DIAGNOSIS AND TREATMENT PLANNING IN CONSERVATIVE DENTISTRY AND ENDODONTICS

Introduction

Definition : Diagnosis (According to McGhee – Grossman)

Differential diagnosis

Prognosis

Treatment plan (Sturdvent – operative dentistry 4th edition)

Working diagnosis

Definition diagnosis

* Pretreatment considerations

- Chief complaint

- Medical History

- Sociologic and Psychologic review.

Past

- Dental History

Present

- Risk Assessment.

* Examination and Diagnosis

- Extra oral examination

- Intra oral examination

a. Soft tissue

Charting and records

b. Hard tissue

Tooth denotation systems.

c. Clinical examination of caries.

- Occlusal caries.

- Smooth surface caries.

- Root caries

ii. Clinical examination of additional defects

- Tooth wear

- Developmental defects

iii. Clinical examination of trauma

iv. Examination of amalgam restorations

v. Examination of cast restorations

vi. Examination of tooth colored restorations

vii. Examination of Periodontium

viii. Examination of occlusion

ix. Examination of Pain

- Definition (According – Fields IASA)

- Pulp pain – classification (Ingle – 5th edition endodontics)

- Diagnosing tooth ache.

* Diagnostic aids in caries.

Old Trends

1. Visual Detection

2. Tactile sensation with explorers

3. Radiographs

4. Temporary elective separation and impression.

5. Caries detector dyes.

Newer Trends

1. Computer based image analysis.

2. Quantitative light induced fluorescence (QLF)

3. Electro conductness measurements (ECOM)

4. Digital fibre optic transillumination (DIFOTI)

5. Endoscopic filtered fluorescence (EFF)

6. Alternating current infedence spectroscopy technique.

7. Megnetic resonance micro imaging (MRM)

8. Ultra sonic Imaging

9. Diagnodent laser diode fluorescence

10. Strey field imaging (SFRAF1)

11. Radio visiography (RVG)

12. Caries activity tests

* Diagnostic AIDS in Endodontics

1. Visual and Tactile Inspection

2. Palpation

3. Percussion

4. Mobility and Depressability tests.

5. Periodontal examination

6. Radiographic examination

7. Xeroradiography.

8. Digital substraction radiography.

Vitality tests

1. Thermal tests

Heat & Cold

2. Electric Pulp test

3. Test cavity

4. Anaesthetic Test

5. Laser Doppler Flowmetry (LDF)

6. Pulse – Oximetry.

7. Liquid crystal testing.

8. Hughes probeye camera

Newer Methods

- Ultra Sounds Real time imaging

- Computerized Tomography

- Magnetic resonance imaging

- Computerized export system.

- Tuned aperture computed tomography (TACT)

- Infrared Thermography.

* Diagnosis of cracked tooth syndrome

* Treatment Planning.

1. Urgent Phase

2. Control Phase

3. Re-evaluation Phase

4. Definitive Phase

5. Maintenance Phase

* Conclusion

* References

Introduction

Pretreatment considerations consisting of patient assessment, examination and diagnosis

and treatment planning are the foundation of sound dental care. These considerations follow a

step wise progression as the diagnosis and treatment plan depend on thorough assessment and

examination of the patient.

Diagnosis

“Is defined as correct determination, discriminative estimation and logical appraisal of

conditions found during examination as evidenced by distinctive marks, signs that are

characteristic of health or disease”. - McGhee.

Diagnosis

“is the process of identifying a disease by its signs, symptoms and results of various

diagnostic procedures” - Grossman.

Differential diagnosis

Is the list of most likely and possibly diagnosis based on available information”. The

final diagnosis is only arrived at, after other diseases on this list have been eliminated through

further investigations or consultations. - Webster Dictionary.

Prognosis

“Predicting the likely outcome of a disease based on condition of patient and action of

disease. - Webster Dictionary

Treatment plan

“Is a carefully sequenced series of services designed to eliminate or control etiological

factors, repair existing damage and create a functional, maintainable environment. – Text book

of operative Dentistry – Sturdvent.

“Working diagnosis”: after eliminating as many diseases (differential diagnosis). From

consideration as the information justifies, the remaining possibilities are ranked in the order of

diagnostic probability. The most likely diagnosis is referred to as the “Working diagnosis”, the

“presumptive diagnosis” or “Clinical impression” or “Provisional diagnosis” Gary C. Coleman.

* Additional tests and preliminary treatment limits the list to a single disease, which is the

“Definitive diagnosis”, “Final diagnosis” or just “diagnosis”. The final diagnosis determines the

definitive management of the problem – Gary C. Coleman.

PRETREATMENT CONSIDERATIONS

* Chief Complaint

- Before initiating any treatment it is important to determine the patients chief complaint or

the problem that initiated own words.

- It is recorded in patients own words.

- Patient should be encouraged and guided to discuss all aspects of current problem,

including onset, duration symptoms and related factors.

Symptoms

Are the units of information sought in clinical diagnosis. It is defined “as phenomena or

signs of a departure from the normal and indicative of illness”. By Gross man.

Subjective symptoms

Are those symptoms ascertained by the clinician through various tests.

It thus follows that the corners or pillars of a correct clinical diagnosis are

a. Good case history

b. A thorough clinical examination and

c. Relevant investigations / diagnostic tests.

Medical history

- Medical history helps identify conditions that could alter, complicate or contra indicate

proposed dental procedures.

- For example : 1. Communicable diseases : Viral infections like hepatitis, AIDS that

require special precaution procedures or referral.

2. Allergic or medications : Patients allergic to local anesthetics like “Novacaine” may

contra indicate use of certain drugs.

3. Systemic diseases and cardiac abnormalities like rheumatoid heart diseases that

demand less strenuous procedures or prophylactic antibiotics coverage.

4. Physiologic changes associated with aging : may alter clinical presentation and

influence treatment.

- Even though there are virtually no systemic contraindication to endotherapy (except

uncontrolled diabetes or recent myocardial infarction), a recent, comprehensive medical

history is mandatory.

- Patients with systemic conditions like heart valve replacement, a history of rheumatic

fever or advanced AIDS require antibiotic prophylaxis.

- Patients who are on anticoagulant therapy may need to have the dose reduced or

suspended.

- During endodontic treatment, clinician must know what drugs the patient is taking so that

adverse drug interactions can be avoided.

- In case of patients with mental or emotional disorders, medical consultation before

diagnostic examination would be best.

* Sociologic and Psychologic review.

- During initial visits the clinician should ascertain the patients attitudes, priorities,

expectations and motivations towards dental care.

- Attitudinal information combined with assessment of the patients dental appreciation,

educability habits, parental history, occupation and financial situations can indicate the

patients commitment to dental care.

- Diet - since diet plays a major role in dental caries and is of importance in tooth wear.

- Habits - it is relevant to enquire about tooth, cleaning habits and the tooth paste used as

well as other habits. Example smoking will increase the likelihood of surface stains on

teeth. Grinding habits, an erosive diet or alcohol consumptions are also relevant.

Past

Dental History

Present

Past dental history

Reveals information about past dental problems and treatment. If a patient has difficulty

tolerating certain types of procedures or has encountered problems with previous dental care, an

alteration of the treatment or environment may help avoid future complications.

Also important to know the date and type of available radiographs to ascertain the need

for additional radiographs and minimize the patients exposure to radiation.

Present dental history

The most common complaint that leads to dental treatments is pain or swelling.

Questions like when did you first notice this (Inception), factors that improve or worsen

the condition (Provoking factors). Factors that relieve the pain host or cold (attenuating factors).

(Frequency ) of pain

(Intensity) of pain is mild, moderate or severe.

(localized or referred) location of pain

(Duration) of pain, momentary or long lasting

(Postural) pain is when you bend or lie down.

(Stimulated or spontaneous) pain.

- (Quality) of pain is sharp, lancinating, stabbing, dull or throbbing, growing.

Treatment

Diagnosis

Consult Referral

Data Evaluation

Radiographic Interpretation

Diagnostic Physical

Tests Inspection

Medical Dental Patient

History History Interaction

Chief complaint

* Risk Assessment

- Patient should me made aware of their risk status.

- This knowledge encourages them to keep appropriate recall appointments and to become

involved in their own preventive care.

- A cluster analysis model for caries risk assessment was applied to determine, the natural

grouping of individuals among sixty 8-10 year old children and to identify the most

significant set of markers for risk assessment.

- Risk clusters were obtained with initial clinical and bacteriological measurements

including DMF + DMFS, active caries, mutans streptococci and lactobacillus counts in

plaque or saliva and synderi test.

- This set of markers identified 86% of children at high risk and 94% of children in low

risk cluster.

Sanchez-Perezl et al (Arch oral Biol.2004, Sept. 49(9) 719-25)

CARIES RISK ASSESSMENT

High risk Low Risk

Social History

Socially deprived

High caries in siblings

Lower knowledge of dental

disease

Irregular attendance

Ready availability of snacks

Low dental aspirations

Middle class

Low caries in siblings

Dentally aware

Regular attendance

Work does not allow regular

snacks.

High dental aspirations

Medical History

Medically compromised

Handicapped

Xerostomia

Long term cariogenic medicine

No medical problem

No physical problem

Normal salivary flow

No long term medication

Dietary habits

Frequent sugar intake Infrequent sugar intake

Fluoride use

Non-fluoride area Fluoridation area

No fluoride tooth paste Fluoride tooth paste used

Plaque control

Infrequent, ineffective cleaning

Poor manual control

Frequent, effective cleaning

Good manual control

Saliva

Low flow rate Normal flow rate

Clinical Evidence

New lesion s

Premature extractions

Anterior caries or restorations

Multiple restorations

History of repeated restorations

Partial dentures

No new lesions

Nil extraction for caries

Sound anterior teeth

No or new restorations

Restorations inserted year age.

No appliances

* Examination and diagnosis

Extra oral examination

General – Built, gait

Local

- Should begin while clinician is taking patients dental history by observing the patients

facial features.

- Look for facial asymmetry or distension that might indicate swelling of odontogenic

origin or systemic ailment.

- Patients eye for papillary dilation or constriction that may indicate systemic disease,

premedication or fear. Lips -> competent or incompetent.

- Patients skin for any lesions (S), if more than one, whether lesions appear at random or

follow neural pathway.

- Examination of sub mandibular glands sub-mental and cervical nodes. For abnormalities

in size, texture, mobility and sensitivity to palpaton (Bimanual palpation).

- Masticatory muscles for pain or tenderness, examination of TMJ – deviation, clicking,

tenderness.

- Vital signs

Blood Pressure : Normal – 120/80 mm Hg for below 60 years.

140/90 mg Hg above 60 yrs.

It must be stressed that no patient with or without a dental emergency, should be

treated when his diastolic B.P. is over 100 mm Hg.

- Pulse Rate and Respiration : Normal : Pulse : 60-100 /minute.

Respiration : 16-18/minute

- Temperature : Normal body temperature : 37oC. 98.6 oF.

- An elevated body temperature is one indication of total body reaction to inflammatory

disease.

- A temperature above 98.6 of but less than 100oF indicates localized disease (Summers

G.W. 1976).

Intra oral examination

Soft tissue

Visual examination and palpation of buccal muocsa buccal vestibules, hard palate, soft

palate, lips, tonsillar areas, tongue and floor of the mouth.

- Hard tissue

- Charting and Records : Charting system includes identification data, medical history,

dental history, clinical examination, diagnosis, treatments planning documentation or

informed consent, progress notes and completion notes.

- Charting system is necessary for many reasons including :

* Proper care

* Quality assessment

* Legal proceedings

* Forensic uses.

- Tooth Denotation system

Palmer system - common in U.K.

8 -1 1-8

8 -1 1-8

Designated as 6

Letter code - UR UL

LR LL

- Designated as UL 6

Federation Dentaire – common in Europe

International (FDI)

- 1 2

4 3

- Designated as 26

Universal – Common in U.S.A.

- 1 16

32 17

- Designated as 14

* Clinical examination of caries

The pre requisites for caries diagnosis are :-

Good lighting

Clean teeth

A three in one syringe so that teeth can be viewed both wet and dry.

Sharp eyes with vision aided by magnification

Reproducible bitewing radiographs

Examination of caries on occlusal surfaces

- Caries is most prevalent in faulty pits / fissures of occlusal surfaces where developmental

lobes of posterior teeth foiled to coalesce partially or completely.

- Occlusal surface is diagnosed as diseased if any one of the findings is present.

Chalkiness or softening of the tooth structure forming the fissure / pit.

Brown – grey discoloration radiating peripherally from the fissure / pit.

Radiolucency beneath the occlusal enamel surface

- Active uncavitated lesion is white, often with a mark surface.

- Corresponding inactive lesion may be brown.

- These enamel lesions are not visible on a bitewing radiograph.

- Enamel lesion that is only visible on a dry tooth surface is in the outer enamel.

- Lesion visible on a wet surface is all the way through the enamel and may be into

dentine.

- Cavitated lesions present as micro cavities with or without grayish discoloration of

enamel

- A lesion missed on visual examination but found on radiograph - “Hidden caries”.

Examination of caries on proximal surfaces.

- Difficult to see a carious enamel lesion as they form just cervical to contact area and

vision obscured by adjacent tooth.

- Because if lesion is discovered clinically, it is usually at a relative late stage when it has

progressed well into dentine and seen as pinkish grey area shinning up through marginal

ridge.

- Bitewing radiographs – important in diagnosing approximal caries in both enamel and

dentine

- And once lesion is visible in enamel on bitewing radiograph it is usually in dentine when

examined histologically

- Approximal enamel lesion appears as dark triangular area in enamel on a radiograph,

apex towards the enamel dentine junction.

- Caries on approximal root surface is visible on bitewing radiograph; sometimes it is

confused with a cervical radio lucency or “burnout”. This is a perfectly normal

appearance at the gap between dense enamel over crown of the tooth and crest of alveolar

ridge where x-ray pass tangentially through dentine of root (not through enamel or bone)

giving a relatively radio lucent appearance.

- Transmitted light used in diagnosis of approximal caries in anterior teeth.

- In posterior teeth, a stronger light source is required and fibre optic lights with beam

reduced to 0.5 mm diameter have been used.

* Examination of root surface caries

- Uncavitated, active lesions are close to gingival margin and have mark surface.

- Inactive lesions are further from the gingival margin, white or brown in color with a

shiny surface.

- Active lesions are soft, plaque covered arrested lesions are hard and plaque free.

- Incipient caries on facial and lingual smooth surfaces appear as white spot which will

partially or totally disappear. From vision on wetting. Drying again will cause it to

reappear.

- This disappearing – reappearing phenomenon helps to distinguish between smooth

surface incipient caries and non-hereditary enamel hypocalcification (Does not disappear

on wetting).

Clinical examination of additional defects

Tooth wear

Chemical erosion: is the loss of surface tooth structure by chemical action in the

continued presence of demineralizing agent (Acid.)

Resulting defective surface is smooth

Exogenous acidic agents such as gastric fluids cause generalized erosion of lingual,

incisal and occlusal surfaces.

Idiopathic erosion - cervical wedge shaped defect (angular), predominant causative

factor is heavy force is eccentric occlusion resulting in flexuring of the tooth.

This tensile stress in the effected wedge shaped region on the tooth side away from the

tooth bending direction, results in loss of surface tooth structure by Micro fracture

termed “abfraction”.

Abrasion: is abnormal tooth surface loss resulting from direct frictional forces between

the teeth and external objects, or from frictional forces between contacting teeth in the

presence of an abrasive medium.

Seen as a sharp wedge shaped notch in the gingival portion of facial aspect of teeth,

surface of defect is smooth.

Usually caused by improper brushing techniques

Present on such defects does not automatically warrant intervention, rather it is important

to determine and eliminate the cause.

Attrition

Is mechanical wear of incisal or occlusal tooth structure as a result of functional or

parafunctional movements of the mandible.

- Certain degree of attrition is expected with aging, but in case of a significant abnormal

attrition, the patients functional movement must be evaluated and enquiring made about

any habits creating this problem such as tooth grinding or bruxism usually due to stress.

- Developmental defects

- Acquired

- Hereditary

Acquired

1. Enamel hypoplasia and Hypomineralization

- Hypoplastic enamel results from production of reduced amount of matrix which natures

normally, because enamel is pitted or thin but of normal hardness.

- Hypomineralized enamel results when normal amount of matrix fails to achieve full

mineralization. Affected enamel has normal shape and thickness but has opaque chalky

white appearance.

- Majority of systemic disturbances last only a few weeks and because the defect takes the

form of narrow horizontal band around affected crown and crowns

- Hypomineralization affecting occlusal surfaces appear white yellow or yellow brown

opacities that chip off easily leading to unprotected dentine, plaque stagnation and rapid

caries development.

2. Dental Fluorosis

- Occurs when total daily intake of fluoride ion is high while the enamel is undergoing pre

eruption formation and maturation.

- Appears as chalky – white flecks or confluent blotches and brown discoloration

sometimes accompanied by pitting of enamel

3. Tetracycline staining

- Occurs when drug is taken by infants and young children or pregnant women where in the

developing permanent teeth are affected showing horizontal band of discoloration.

Hereditary conditions

1. Hypodontio, microdontia -> teeth abnormal is shape or size.

- Upper lateral incisors, upper and lower second premolars and third molars most

commonly affected.

2. Amelogenesis imperfecta: - Two different patters

a. Generalized hypoplasia : defect in enamel matrix formation, appear yellow with

thin enamel or granular or pitted enamel surfaced which may pick up stain.

b. Generalized hypomineralization : incomplete mineralization of normal matrix.

Enamel may appear stained and darkened or dull and chalky –white.

3. Dentinogenesis imperfecta : deficient formation of dentin and is characterized by brown

opalescent discoloration of teeth which are prone to early fracture and excessive wear.

* Examination of trauma

- Crowns of the teeth examined for fracture, pulp exposure and color changes.

- Displacement or looseness of teeth should be noted.

- Check for abnormalities of the occlusion.

- Vitality of the injured and adjacent teeth must be tested.

- Periapical radiographs taken to look for root fracture.

- Where fractures of maxilla or mandible are suspected, further radiographs of facial

skeleton required.

- At subsequent recall visits the color of the tooth and further vitality tests and periapical

radiographs will show whether pulp has remained vital or not.

* Examination of amalgam restorations

- Amalgam restorations are evaluated for

Amalgam blues

Proximal overhange.

Marginal gap or ditching.

Voids

Fracture lines

Interface lines

Improper anatomical contours.

Marginal ridge incompatibility

Improper proximal contacts

Recurrent caries.

Examination of cast restorations

- Is evaluated clinically in the same manner as amalgam restorations.

- If restorations are not satisfactory or carrying tissue harm it is classified as defective and

considered. For recontouring, repair or replacement.

Examination of tooth colored restorations

Any improper proximal contact, contour, overhanging proximal margin, recurrent caries

then the restoration is considered defective. If dark marginal staining or discoloration present,

esthetically displacing then replacement.

Examination of Periodontium

Clinical examination

- Gingival color and texture is examined as they are important indices of periodontal

health.

- Depth of gingival sulcus around each tooth is determined. Presence of pocket (Sulcus

depth greater than 3mm) or haemorrhage or exudates indicates periodontal disease.

- Evaluate presence of bifurcation or trifurcation involvement – affects long term prognosis

of the tooth.

- Note areas of gingival recession

- Teeth should be evaluated for mobility -> as it indicates significant loss of bone support

which could affect subsequent operative treatment.

Radiographic examination

- Bitewing radiographs help in assessing bone levels.

- Radiographs aid in determining the relationship between the margins of existing or

proposed restorations and the bone.

Examination of occlusion

- The static relationship of the teeth in intercuspal position (ICP) should be examined to

determine the horizontal and vertical overlap of the anterior teeth, together with the

relationship of posterior teeth.

- The way in which the teeth, function against each other in forwards, backwards and

lateral movement of the mandible should be examined. Examination should also look for

“Plunger cusp” which is a pointed cusp plunging deep into the occlusal plane of the

opposing arch. This may result in food impaction or tooth/restoration fracture.

Examination of pain (Tooth ache)

Field defined pain as “an unpleasant sensation that is perceived as arising from a specific

region of the body and is commonly produced by processes that damage or are capable of

damaging bodily tissue”.

International Association for the study of pain (IASP) defined pain as “An unpleasant

sensory and emotional experience associated with actual or potential tissue damage, or described

in terms of such damage”.

Pulp pain: or pulpalgia, is the most commonly experienced pain in and near the oral

cavity and may be classified according to degree of severity and the pathologic process present :

1. Hyper reactive pulpalgia.

a. Dentinal hypersensitivity

b. Hyperemia

2. Acute Pulpalgia.

a. Incipient

b. Moderate

c. Advanced

3. Chronic Pulpalgia

a. Barodontalgia

4. Hyperplastic pulpitis

5. Necrotic pulp

6. Internal resorption

7. Traumatic Occlusion

8. Incomplete fracture

Mildest pulp discomfort, experienced when no inflammation is present; is hyper reactive

pulpalgia

Quality of pain: Pulp pain are of two varieties

a. Sharp, piercing an lancinating a painful response associated with excitation of the A-delta

fibres (Myelinated, post conducting and low pain threshold)

Cold stimulates the fast conducting as fibres

This pain usually reflects reversible state.

b. Dull, boring, gnawing and extruciating - a painful response usually associated with C-

nerve fibres (Unmyelinated, slow conducting and higher pain threshold). Heat usually

stimulates the slow conducting (Fibres * This pain usually reflects an irreversible state of

pulpitis.

Pulpal and periapical pathosis produce sensations that are described with terms such as

- Aching

- Pulsing

- Radiating

- Flashing

- Zolting

- Electric

- Recurrent

Duration of pain

- Pain of shorter duration, is considered to be reversible pulpitis, whereas when pain is of

longer duration irreversibly.

- Tooth with pulpal pain that disappears on removal of irritant has shown excellent chance

of recovery without the need of endodontic treatment.

Inception

1. Mode : Spontaneous or provoked, sudden or gradual, stimulated

* Immediate

* Delayed

2. Periodicity: Symptoms have temporal pattern or sporadic or occlusional, recurrent pain.

3. Frequency: Continuous or Intermittant.

Intensity of pain

1. Quantify the pain by assigning to the pain a degree of 0 (none) to 10 (intolerable pain)

helps to monitor patrents perception of pain throughout the treatment.

2. Mild, moderate or severe.

Predisposing factors

- Factors that can precipitate the onset of symptoms which may indicate a non-odontogenic

cause.

- Postural changes : Jaw pain or headache on bonding over, blowing the nose or jogging

-> maxillary sinusitis

- Time of day - stiffness and pain in jaws and masticatory muscles a waking – TMJ

dysfunction. Pain on strenuous or vigorous activity -> pulpal or periapical inflammation.

- Hormonal change “Menstrual tooth ache” or recurring hypersensitivity may occur due

to increased body fluid retention. Symptom disappears when the cycle ends.

Referred pain

Common in advanced pulpitis. Posterior molar pain often referred to opposing quadrant.

Maxillary molars to -> zygomatic, parietal and occipital regions of the head.

Lower molars to -> ear, angle of the jaw or posterior region of the neck.

Localization of pain

Sharp piercing pain can usually be localized and responds to cold.

Dull pain usually referred / spread over a large area responds more abnormally to heat.

Patient may report dental pain that is exacerbated while lying down or bending over. This

occurs because of increase in blood pressure to the head, which subsequently increases

the pressure on the confined pulp.

Factors which provoke (relieve pain) (IEJ, 1990 by AH. Rowe et al)

- On assessment of pulp vitality by A.H. Rowe et al, response to a provoking factor (E.g.

on mastication) indicates pulp vitality, but stimulation causing extended severe pain

suggests irreversible pulpitis.

- Heat, cold, sweets, percussion, biting, chewing, palpation.

Diagnosing toothache.

A patient complaining of toothache is most likely to be suffering from one of the

following conditions.

Acute Pulpitis

Acute apical periodontitis

Acute apical abscess

Acute periodontal abscess

Chronic pulpitis

Chronic apical periodontitis

Exposed sensitive dentin.

Food packing

Cracked cusp

Pulpitis resulting from caries is most common cause of tooth ache.

Several other conditions of mouth and face may be confused with tooth ache. Example :

Maxillary sinusitis.

* Pericoronitis

* Trigeminal neuralgia

Mandibular dysfunction

Atypial facial pain

Lesions of salivary glands and soft tissue.

Acute pulpitis

Severe pain, poorly localized to the tooth

Two clinical presentations

* Reversible

* Irreversible

Differential diagnosis of reversible and irreversible pulpitis.

Reversible Irreversible

1. History Slightly sensitivity or

occasional pain

Constant or intermittent

pain

2. Pain Momentary and immediate,

sharp in nature and quickly

dissipates after removal of

stimulus.

Continuous, delayed

onset, throbbing, persists.

For minutes to hours after

removal of stimulus

3. Location of pain May be localized and not

referred

Pain not localized it

localized only after

peripheral involvement.

Pain is refe…..

4. Change of posture No difference Pain increases

5. Thermal test Responds Marked prolonged.

6. E.P.T Early response Early, delayed or mixed

response

7. Percussion Negative Negative in early stages

later positive when

periapex involved.

8. Radiography Negative May show widening of

periodontal ligament

space.

Acute apical Periodontitis

- Classical presenting sign is that patient presenting indicating which tooth is causing

pain, whereas patient with acute pulpitis holds their hand to the side of their face.

- Tenderness on percussion

- Pulp contains pain nerve endings only but the periodontal ligament contains both pain

and pressure sensitive nerve endings.

Acute apical abscess

- Patient presents with a large tender swelling, either intra orally or on the face.

- Sometimes patient presents before swelling has appeared or after it has spontaneously

burst or subsided.

- Patient may feel unwell and have a temperature.

- Pulp usually gives a non vital response.

Acute Periodontal abscess

- Forms at the base of deep periodontal pocket, presentation similar to acute apical

periodontitis or acute apical abscess but tooth may still be vital.

- In some cases infection arising from deep pocket meets with infection arising from

necrotic pulp ->perio -> endo lesion (Poor prognosis).

Chronic Pulpitis

- Produced mild, poorly localized pain which sometimes comes and goes over a period

of weeks or months.

- If untreated, pulp becomes non-vital and symptoms of chronic pulpitis disappears

- Responds to vitality test.

- Not tender or percussion

Chronic apical periodontitis.

- Symptomless condition, may feel mild pain on biting.

- Vitality test negative.

- Slightly tender to percussion (Dull note)

- Main diagnostic sign - is peri apical radio lucency seen.

- When sinus is present - gutta percha point will show approaching the apex of the

relevant tooth on the radiograph.

- In all above condition, no radiographic changes in periapical tissues except a slight

thickening of apical periodontal space with acute apical abscess.

- In chronic state, apical granuloma not infected -> chronic inflammatory response to

toxins leaching from apex of tooth with necrotic pulp.

- These toxins are diluted because natural limit to size of chronic periapical granuloma

- Beyond this size, toxins are too dilute to stimulate osteoclastic action.

- A peripheral granuloma, highly vascularized repair tissue, because after root canal

therapy granuloma replaced by normal bone.

- Chronic apical granuloma

May become infected or may become

And flare up into an cystic, which also

Acute apical abscess can become infected

(Phoenix abscess) and flare up into A.A.A.

Exposed sensitive dentin

- May result from gingival recession or surgery producing exposed root surfaces,

failing restoration or caries exposing dentine to oral fluids.

- Sensitivity to hot, cold. Sweet. Food & drink.

- Poorly localized

Food packing

Contact point not tight due to teeth drifting apart, poorly contoured restoration. Food

wedges between the teeth and causes periodontal pain.

DIAGNOSTIC AIDS IN CARIES

The coronal carious lesion starts as a clinical undetectable sub surface demineralization with

further progression, it will eventually become clinically detectable.

Apart from, for the occult fissure penetrating deeply into the dentin, dilemmas in clinical

detection and registration arise not with the advanced lesion, but primarily with the early lesion

(confined to out enamel), the non-cavitated lesion of dentin, recurrent caries (around the margins

of restoration) and sub gingival root caries.

According to Pitts (1997), the ideal method or toot for diagnosis of carious lesions would be

non-invasive and provide simple, reliable, valid, sensitive, specific and robust measurements of

lesion size and activity and be based on biologic processes directly related to the carious

process.

Diagnostic tools.

Some decades ago, visual diagnosis (light and mirror) and probing, supplemented by bitewing

radiographs were the only roots available for clinical diagnosis of caries.

These tools detected the presence of cavitation rather than measuring the disease as a continuous

process that starts from the appearance of microporosity as a result of demineralization leading

to cavitation.

The radiographic image of occlusal fissure is complex and is such that caries would only be

visible when it affects the base of the fissure. Occlusal caries progresses along the fissure walls,

finally reaches dentin.

Old trends

1. Visual detection

Combination of light and minor

Most commonly applied method

Sensitivity is low, specificity high

Major shortcoming is that this method is very limited for detecting non-cavitated lesions in

dentin on the posterior approximal and occlusal surface.

2. Tactile sensation with explorers

Caries is diagnosed if tooth meets the ADA criteria of softened enamel that catches an explorer

and resists its removal or allows the explorer to penetrate proximal surface under moderate to

firm probing pressure.

In recent years, it has been shown that a sharp explorer may cause cavitation of an intact surface

enamel with sub surface demineralization (Bergnan and Linden 1969, Quist and Thylstrup 1987)

and could force cariogenic bacteria into depth of lesion.

3. Radiographs

Bitewing and periapical radiographs commonly used.

Also occlusal radiographs, panoramic radiographs are sometimes indicated

The diagnostic yield that could be gained from a radiograph outweighs the potential adverse

effects of exposure to radiation.

Radio graphs have some limitations

2 dimensional representation of 3 - dimensions object.

Interpretation would produce certain false - positive and false negative diagnosis

Does not diagnose earliest stages of lesion.

Approximal caries (secondary) on more apical part of restoration may not be

detected.

Non cavitation carious lesion on the root are difficult to diagnosis.

The only way to guard against these limitations is to continually correlated clinical

and radiographic findings.

4. Temporary elective tooth separation and impression

Using wedges and elastics

Helps in assessing whether radiographically detectable approximal enamel and dentin lesions

are cavitated.

Combined with localized impression allows a more sensitive diagnosis of cavitation.

5. Caries detector dyes.

- Van de Rijke (1991) reviewed the use of dyes in cariology

- Used clinically to differentiate between outer carious dentin and inner affected dentin

- Outer carious dentin is distinctly stained.

- Fluorescent - Fluoros TGA - sodium fluorescent

Zyglo 21-22, pyrromethene 556.

- Non fluorescent - 1% acid red in propylene glycol

- Carsolen green

- Lssamine blue

- 1% acid red is basically a food dye.

- Iodide penetration method for measuring enamel porosity of incipient smooth surface

lesion was developed by Brudevold and co-workers.

Newer trends

1. Computer – Based image analysis

Recently been applied for examination of dental radiographs.

Program detects a lesion, and designs its borders, measures and reports the lesions parameters,

percent mineralization area and maximal and mean enamel penetration.

2. Quantitative light induced fluorescence (QLIF)

Benedict (1928) first noted fluorescence of organic components of teeth and also the difference

in fluorescence between sound and carious enamel using visible light compared with ultra violet

light

Lesion with depth of only 25 um have been measured.

Demineralized area appears as dark region because of loss of intrinsic fluorescence substances

(hydroxyapatite crystals and tubules) in demineralized enamel and dentin.

Quantitative laser induced fluorescence used organ – ion laser (488 mm).

In some studies, fluorescence dye was applied to the lesion to enhance the difference between

sound and carious tissues.

Currently QLF system uses are lamp filtered to a small band (370 + 80 nm)

Uses because

Early caries detection

Monitoring white spot lesion

Evaluation of quality of fissure sealants and dental restorations (red fluorescence

indicates micro leakage – porphyrins metabolized by bacteria)

Detection of plaque

Limitations

Restricted to smooth surface caries diagnosis.

Should be performed under standardized conditions regarding hydration of tooth

Circular lesion (Mesiobuccal or distobuccal) cannot be detected because optical

axis of QLIF has to be oriented Ist molar to tooth surface

3. Electro conductance measurement (ECM)

Idea of electrical method of caries detection first proposed by Magitot (1878).

Theory: Sound surfaces posses limited or no conductivity, whereas carious or demineralization

enamel have measurable conductivity that increases with increasing demineralization.

Pincus (1951) first suggested the concept of testing for caries through electrical independence.

- Subsequently two instruments were developed in 1980.

1. Vanguard electronic caries detector

2. Caries meter L

Both instruments measured the electrical conductance between the tip of a probe placed in the

fissure and a connector attached to an area of high conductivity (example gingiva and skin).

In vanguard ECD, the recording dial shows number 0-10 and a picture of a “face” that smiles up

“……….” to value of 5 (caries –ve) and frowns “………..” when the value is greater than 5

(Caries +ve)

A new instrument electronic caries monitor is currently being evaluated.

4. Digital fibre optic transmillumination (DIFOTI)

Illumination is delivered by means of fibre optics from a light source to tooth surface. Resultant

changes in light distribution as light transverses the tooth are recorded as image for analysis.

FOTI: designed for detection of proximal caries (Friedman and Marcus, 1970).

Decayed tooth material scakkers light more strongly, thus has lower index of light transmission

than sound tooth structure.

DIFOTI – by combining FOTI and digital CCD camera. DIFOTI can detect incipient and

recurring caries before they are visible on radiographs.

5. Endoscopic filtered fluorescence (EFF)

Endoscopic examination with either white light or filtered fluorescence excited by blue cutting

light was performed by long bottom and Pitts (1990)

Their studies showed that with both methods initial proximal lesions appear darker than

surrounding areas.

6. Alternating current inpedence spectroscopy technique (ACIST)

A more sophisticated approach to lesion detection and measurement is to characterize

the electrical properties of the tooth and lesion by using ACIST which scans multiple

frequencies.

The ACIST is new and has been evaluated only to a limited extent on whole carious

teeth.

7. Magnetic resonance micro imaging (MRM)

Significant value in detection of early changes in mineralized dental tissue.

Non invasive and non destructive

Its use allows a specimen to be reimaged after further exposure to a clinically relevant

environment. When a magnetic field is applied, the nuclear spins align in a finite number of

allowed orientation, if these orientations are perturbed by a pulse of radiofrequency energy, this

energy is absorbed and then retransmitted.

It is this retransmitted energy that is detected.

8. Ultra sonic Imaging

Ultrasonic imaging was introduced by Ngo et al (1988) as a method for detecting early caries in

smooth surface.

They showed (in vitro) that artificial enamel lesions less than 57% of sound enamel mineral

content in the body of the lesion could be differentiated acoustically from intact enamel on the

basis of amplitude changes.

The authors concluded, however, that the method is not yet sensitive enough to detect changes

of shallow caries lesions in vivo.

9. DIAGNODENT.

Tooth surface is illuminated with pulses of red laser light, and fluorescence emitted from the

surface is analyzed and qualified.

Caries lesions alter the amount of fluorescence that can be seen as increased needing.

A valuable adjunct for occlusal caries detection in permanent teeth (Lussi et al 1999)

Commercial development is chairside, batteria powered Diode laser fluorescence device.

This unit emits light at 655 non wave length from fibre optic bundle directed onto occlusal

surface. A second fibre optic bundle receives the reflected fluorescence light beam and changes

caused by demineralization are displayed as numerical value on the monitor.

A laser probe is used to scan over the fissure area in sweeping motion.

Numerical value

* 5 – 25 indicate initial lesion in enamel

* Greater than 25 – early dentinal caries

* Greater than 35 – advanced caries.

- Limitations

Depth of penetration of light limit to 2 mm.

Detects only occlusal involvement not approximal surfaces.

10. Stray – Field Imaging (STRAFI)

- is a magnetic resonance microscope, that shows outer and inner contours of the teeth.

- The resolution in MR imaging is provided by change of magnetic field.

- A non destructive way to examine root canal morphology.

11. Radio Visuography (RVG)

- Digitizes ionizing radiation and provides an instantaneous image on a video monitor

thereby reducing radiation exposure by 80%.

- Has a fibre optic intra oral sensor.

- Advantages

Elimination of x-ray sensor.

Significant reduction in exposure time

Instantaneous image display.

- Has 3 components

1. “Radio” a hypersensitive intra oral sensor and a conventional x-ray unit.

2. “Visio” consists of video monitor and display processing unit.

3. “Graphy” component – high resolution video printer that instantly provides a

hard copy of screen image.

- Resolution is slightly lower then conventional films, however can be improved

through enhancement procedures.

12. Caries activity tests

- Helps in identifying high risk groups and individuals.

1. Lactobacillus colony count tests

Introduced by Hadley in 1933, popularized by jay.

No of lactobacillus colonies in saliva are related to caries susceptibility

2. Colorimetric Snyder test

Measures the ability of salivary m.o. to form organic acids from a CHO medium,

which contains indicator dye, Bromocyes of green.

Rate of color change from green to yellow is indicative of the degree of caries

activity.

3. Swab test

Developed by Grainger 1965.

Swab is incubated in the medium for 48 hrs, change in pH is indicative of degree

of caries activity.

4. Salivary Buffer capacity.

Volatile bicarbonate onion is the important component of salivary buffer system.

Saliva samples requiring less than 0.45 ml of standard Hcl have low buffer

capacity and those requiring 0.45 ml or more have high buffer capacity.

5. Streptococcus mutans level in saliva.

- Measures the number of streptococcus mutan colony forming units per unit volume of

saliva.

6. Enamel solubility test

Glucose is added to saliva containing powdered enamel.

Thus organic acids are formed, which decalcify the enamel, resulting in increase in

soluble calcium which is a direct measure of degree of caries susceptibility

7. Salivary reductable test

Measures the activity of reductable enzyme present in salivary bacteria.

8. Alban Test

Simplified form of Synder Test

Measurement of salivary flow rate

Easy to measure at the chair side.

Patient chews paraffin wax to stimulate saliva for 1 min and spits it into a

measuring cylinder.

Stimulated salivary flow rate a expressed in milli litres (ml) per minute.

Normal rate in adults = 1-2 ml/min.

Xerostomia = 0.7 - 0.1 ml / min.

DIAGNOSTIC AIDS IN ENDODONTICS

1. Visual and Tactile inspections

Examination of hard with soft tissue for 3 C’s : Color, contour and consistency

Soft tissue

Color: Normal color of gingiva is pink, change from this is easily visualized in

inflammatory conditions.

Contour: change in normal contour (Scalloped gingiva) occurs with a swelling.

Consistency: on inspection (gingiva) appears health, firm, resilient, while a soft,

fluctuant or spongy tissue is move indicative of a pathological state.

Hard tissue

Color: Normal teeth show life like translucency and sparkle that is missing in pulpless teeth

which appear more or less opaque.

Contour: examination of contours of effected teeth, such as fractured teeth, wear facets,

improperly contoured restorations or altered crown contours as these factors can have marked

effect on the respective pulps.

Consistency: change in consistency is related to presence of caries, external and internal

resorption.

- Presence of sinus tract opening into gingival crevice and deep pockets are discovered by

tracing with a gutta percha cone.

2. Palpation

Simple test done with finger tip using light pressure to examine tissue consistency

and pain response.

Helps to determine the following

a. Whether tissue is fluctuant and enlarged sufficiently for incision and drainage.

b. Presence, intensity and location of pain.

c. Presence and location of edenopathy

d. Presence of bone crepitus.

When posterior teeth are infected, sub maxillary lymph nodes are usually

involved, anti teeth submental lymph nodes involved.

When infection confined to pulp and not progressed into periodontium palpation is

not diagnostic.

Palpation, percussion, mobility and depressability test check the integrity of

attachment apparatus and not the condition of pulp.

3. Percussion

Tooth is struck with a quick, moderate blow initially with low intensity by the

finger, then with increasing intensity by the finger, then with increasing intensity

by using handle of an instruments.

A positive response to percussion indicates not only the presence of inflammation

of periodontal ligament but also the degree of inflammation.

Periodontitis can also occur around tooth with vital pulp as in rapid ortho

movement, recently placed restoration in hyper occlusion.

Chronic peri apical inflammation often yields negative result with percussion.

Dull note – signifies abscess formation

Sharp note – denotes inflammation (Ingle)

4. Mobility and depressability tests

Rationale of mobility test is to evaluate the integrity of the attachment apparatus

surrounding the tooth.

Test consists of moving the involved tooth facio-lingually using handles of two

instruments or using two index fingers.

Test for depressibility is performed by applying pressure in an apical direction on

the occlusal/incisal aspect of tooth and observing vertical movement if any. When

this exists chances for retaining the tooth ranges from poor to hopeless.

Grades of mobility (Grossman & Cohen)

Grade I (First degree) - Less than 1 mm of horizontal movement.

Grade II (Second degree) – Lateral (Horizontal) movement of around 1 mm.

Grade III (Third degree ) – greater than l mm of horizontal movement

accompanied by vertical depressability

Grades of mobility (miller)

0 - Non mobile / mobility within physiological limits

1 - Mobility within range of 0 – 0.5 mm

2 - mobility with 0.5 – 1.5 mm with lateral movements.

3 - Mobility more than 1.5 mm with lateral movements and can be depressed

into the socket

Endo treatment should not be carried out on teeth with third degree mobility

unless mobility is reduced by drainage of acute apical abscess.

Mobilometers

are electronic devices / gad gets, which aid in determining tooth mobility

Apparatus consists of two electrodes (Prays which hold facial and lingual surface

of the teeth.

Degree of mobility tested is reflected as a numerical reading.

5. Periodontal examination

Consists use of a blunt celibrated probe to explore the integrity of gingival sulcus

around each tooth.

A significant pocket if present in the absence of periodontal disease it increases the

probability of presence of vertical treatment.

To distinguish disease of periodontal origin from pulp origin, thermal and EPT

along with PDL probing are essential.

6. Radiographic examination

Radiograph is 2 dimensional image of 3 – dimensional tooth because radiographic

strategy should involve the exposure of 2 films at the some vertical angulation but

with 10-15 degree change in horizontal angulation (SLOB rule)

Radiographs can contain information on

1. Presence of caries that may involve or threat on to involve the pulp.

2. May show the number, cause, sharp length and width of root canals.

3. Presence of calcified materials in the pulp chamber or root canals.

4. Resorption of dentin originating with in the root canal or from the root surface.

5. Calcification or obliteration of pulp cavity

6. Thickening of PDL

7. Resorption of cementum

8. Nature and extent of periapical and alveolar bone destruction.

Radiographic interpretation

- A single root canal should appear tapering from crown to apex, sudden change in

appearance of canal from dark to light indicates that the canal had bifurcated or

trifurcated.

- Horizontal root and may be confused radiographically with linear patterns of bone

trabeculae. Lines of bony trabecular extend beyond the border of the root while root

and often cause thickening of PDL.

- Radiographic differentiation of external and internal resorptoin.

Internal R : have sharp smooth margins and the pulp “disappears” into the lesion.

External R : margins not smooth and pulp appears to pass through the lesion

unaltered.

- Shift method can be used to differentiate internal and external resorption, here the position of

internal resorption is unaltered lesions of cancellous bone only are not seem in radiograph until

the cortical bone has been reached or penetrated.

Radiographic misinterpretation

Presence of periapical radiolucency on a tooth does not indicate a diseased tooth. In many

instances an area of rare faction on the root apex may be the super imposition of an image on the

apex.

This phenomenon may be seen, where anatomy is normal as in maxillary sinus, incisive

and mental foramen, medullary space, traumatic bone cysts etc.

A number of pathological changes in and near the alveolar process may be mistaken for

true periapical lesions

1. Non-odontogenic cysts : Lamina dura is intact in all non-odontoblastic cysts

i. Globulomaxillary cyst lesion appears inverted pear shaped

ii. Midline palatal cyst lesion occurs in midline.

2. Apical scar : History of apical surgery intact lamina dura

7. Xeroradiography

Derived from Greek word “Xeros” which means dry.

Uses a rigid aluminium / selenium coated photoreceptor plate. Plate is electrically

charged, placed in a water proof cassette, positioned in the mouth and exposed to

x-rays at a lower level of radiation (25 secs.)

Plates may be reconditioned, recharged and used repeatedly.

Advantages

i. Sharper, cleaner and finer details of images.

ii. Radiation dose reduce

iii. Pronounced edge enhancement.

8. Digital substractions radiography

- Used to detect the progress of caries from an incipient lesion, through the DEJ.

- Assessment of healing or expansion of periapical lesion after root canal therapy.

- Measured the changes in the density of the lesion.

- This is an image enhancement method, resulting in the area under focus being clearly

displayed against a neutral gray black back ground i.e. required areas are enlarged

against the entire background.

VITALITY TESTS

1. Thermal tests

Heat

Cold

Heat / cold tests are performed by placing the stimuli on inciso-labial (anterior)

surface or occluso-buccal (Posterior) surface.

Cold Test

- Includes air blast, cold water bath, ethyl chloride sticks of ice, carbon dioxide ice

sticsk (-78oC) (ehrmann)

- Ethyl chloride and cold water bath are more common, kept in contact with the tooth.

For 5 seconds or until patient feels pain.

- Disadvantage with carbon dioxide Snow -> causes infarction lines in enamel.

- Aerosol of dichloro – difluoromethane was introduced to substitute carbon dioxide

snow

- Heat test

- Can be performed with hot air, hot water, hot burnisher, hot gutta percha, hot

compound polishing of crown with a rubber cup.

- Most commonly gutta-percha stick used.

- Preferred temperature upto 150oF according to Rowe et al (1990) or 65.5oC.

- Responses to thermal tests.

Sensory fibres of pulp transmit only pain whether pulp has been cooled or heated.

1. No response – non-vital pulp is indicated.

2. Mild to moderate degree of awareness of slight pain that subsides within 1-2 sec after

stimulate has been removed – normal.

3. Strong, momentary painful response that subsides within 1-2 secs after stimulus is

removed – reversible pulpitis.

4. Moderate to strong painful response that lingers. For several seconds or longer after

stimulus has been removed – irreversible pulpitis

False positive response can occur -> excossive calcification, immature apex,

recent trauma, premedication.

2. Electric pulp tests

EPT is designed to stimulate a response of sensory fibres within the pulp by

electric excitation.

Disadvantages of EPT

1. Cannot be used on patients having cardiac pace maker.

2. Does not suggest the health or integrity of the pulp, simply indicates the presence

of vital sensory fibres with in the pulp.

3. Does not provide any information about vascular supply of pulp, which is the true

determinant of pulp vitality.

Analytic technology pulp tester widely used.

First lip clip is attached, electrode is coated with viscous conductor (tooth paste)

and applied on the middle third of facial surface of the crown. Current flow should

be increased slowly until the patient feels a tingling sensation.

Thicker enamel – more delayed response

EPT false readings

1. A false positive response means pulp is necrotic, patient feels sensation in tooth.

Reasons

Electrode or conductor contact with metal restoration or gingiva.

Patient anxiety.

Lique faction necrosis may conduct current to attachment apparatus.

Failure to isolate and dry the teeth (saliva)

2. False negative response means that pulp is vital, but patient does not respond,

Reasons

Patient heavily pre medicated with analgesics, alchohol or tranquilizers

Inadequate contact will electrode or conductor and enamel.

Recently traumatized tooth

Excessive calcification of canal.

Recently erupted tooth with immature apex.

Partial necrosis

3. Test Cavity

Performed when other diagnostic methods have failed.

Test cavity is made by drilling through enamel dentin junction of unanaesthetised

tooth.

Sensitivity or pain felt is an indication of pulp vitality.

4. Anaesthesia test

Performed when usual tests have failed to enable one to identify the tooth.

Objective is to anaesthetize a single tooth at a time until the pain disappears and is

localized to specific tooth.

5. Laser Doppler Flowmetry

LDF was introduced (first in 1972 to determine blood flow in retina of rabbits of

Riva, Ross and Bendek) as a non-invasive method to measure the blood flow.

This technique uses a helium neon laser light beam that is directed into the tooth.

Light that contacts a moving object is Doppler shifted, and a portion of that light

to photodetector, and a signal is produced

As red blood cells represents the majority of moving objects within the tooth,

measurements of back scattered light serves as an index of PBF.

Disadvantages is measurements are sensitive to arxe facts such as movement or

pressure, equipment is bulky and costly.

6. Pulse oximetry

Oximetry refers to determination of percentage of oxygen saturation of circulating

arterial blood.

Matthes – father of oximetry (1934 – 1944)

Millikan coined the term “Pulse oximetry”

Probe sensor consists of two light emitting diodes, one to transmit red light (640

mm) and other to transmit infra red light (960 mm) and photo detector on opposite

side of vascular bed.

Well oxygenated blood appears bright red (81%)

7. Liquid crystal testing

Howell et al (1970) employed the color change of cholisteric liquid crystals

applied to surfaces of the teeth, as diagnostic modalities

Changes in temperature or pressure alter the pitch and period of helical structure,

so new colors are produced.

Pulpless teeth exhibited lower surface temperature than those with vital pulp.

8. Hughes Probeye camera

Capable of deteching temperature changes as small as 0.1oC.

Used to measure pulp vitality experimentally

Ultra sound real time imaging

technique that helps in differential diagnosis between cysts and granulomes by

revealing the nature of content of bony lesion.

It widely used in medicine, based on the phenomenon of reflection of ultra sound

waves (echoes) at interfaces between tissues that have different acoustic

properties.

Hypoechoic or transonic – low echo intensity anechoic – no reflection of echoes

occurs in any area filled with fluid.

Hyperechoic – high echo intensity (Bone)

Cystic lesions -> hypo echoic, well contoured cavity, surrounded by reinforced

bone walls, filled with fluids, no evidence of internal vascularization on color

power Doppler examination

Granuloma : Poorly defined lesion, could be hyper echoic or both hypo & hyper

echoic, exhibiting rich vascular supply on color Doppler examination

Computerized tomography

Blends concept of thin laser radiography with the computed image.

Techibena has reported use of CT in endodontics

Possible to determine bucco-lingual and mesio-distal widths of teeth.

Presence or absence of root canal filling materials and posts.

Carious lesions, extension of maxillary sinusitis and proximity to root apices.

MAGNETIC RESONANCE IMAGING

Magnetic fields and radiographic waves are used to generate high quality cross

sectional images of the body.

Can distinguish blood vessels and nerves from surrounding soft tissues.

Disadvantages : Not to be used in patients with cardiac face makers metallic

restorations / ortho appliances, aneurysons.

COMPUTERIZED EXPERT SYSTEM

Reported by John Firriola

Comendex (CES) used for diagnosis of selected pulpal pathosis which is :-

- Normal pulps

- Reversible pulpitis

- Irreversible pulpitis due to hyper occlusion

- Irreversible pulpitis

- Necrotic pulp

- Infection due to endodontic failure

Diagnostic case focks are obtained and this data entered into the computer. The

computer checks and gives out the diagnosis.

Tuned aperture computed tomography (TACT)

New type of imaging device that decreases the super imposition of overlying anatomical

structures.

TACT system uses digital radio graphic images and the TACT soft ware correlates the

individual images of a subject into a layering of images that can be viewed into slices.

TACT image is composed of series of 8 digital radiographs that are assimilated into one

reconstructed TACT image.

Used in visualization of canals in human molars.

Evaluating primary simulated recurrent dental caries and simulated osseous defects.

New tool to diagnosis external root resorption at an earlier stages.

Disadvantage : Slice obtained were 1.25 mm thick which might be too thick and many

of the lesions might have been missed.

Infrared thermography

Alterations in the temperatures of diseased bodily structures have been detected

with sophisticated infrared thermographic equipment.

It has been assumed that teeth with vital pulps would have higher surface

temperature than those with necrotic pulps.

Diagnosis of cracked tooth syndrome.

Cracked tooth syndrome is defined as the incomplete fracture of natural crown of a

premolar or molar tooth.

Gibbs n 1954 – termed it “Cuspal fracture odontalgia”

Ritchey et al 1957 - reported various cases of incomplete fractures with

subsequent pulpitis

Cameron 1964 – termed “cracked tooth sydrome”.

Also called “green stick fracture” or “split tooth syndromes”.

Incomplete cracks are either limited to the crown or may include root also.

Combined fractures are called “split root syndrome”.

1. Transillumination test: Light from fibre optic is applied from buccal surface to

illuminate the tooth to detect fractured lines when present.

2. Biting test – an orange wood stick, or cotton wood stick or rubber wheel or tooth sloth is

placed on occlusal (incisal aspect of the tooth and patient is asked to bite.

Sharp pain on chewing of hard or tough food is very important diagnostic evidence of

cracked tooth. This type of pain is triggered as the pressure is released.

3. Staining: remove the filling from suspected tooth and place 2% Iodine in the cavity

preparation. Iodine stains the fracture like dark methylane blue dye also used.

Mix a dye with ZOE and place it is cavity preparation after filling has been

removed. Dye will seep out and color the fracture line.

Have a patient chew disclosing tablet after taking out filling in suspected fracture

tooth. Line will be stained.

GUTTA PERCHA POINT TRACING WITH A RADIOGRAPHY

Purpose: can localize the endodontic lesion to the specific tooth.

Aids in differential diagnosis between a periodontal and an endodontic lesion.

Technique: place a gutta percha point through the sinus / fistula tract and take a

radiograph.

Treatment planning

A treatment plan is a carefully sequenced series of services designed to eliminate or

control etiologic factors, repair existing damage, and create a functional, maintainable

environment.

Treatment plan sequencing

Urgent phase

Control phase

Re-evaluation phase

Definitive phase

Maintenance phase.

Urgent phase

A patient presenting with swelling, pain, bleeding or infection should have these

problems managed as soon as possible and certainly before initiation of subsequent phases.

Control phase

Is meant to

1. Eliminate active diseases such as caries and inflammation.

2. Remove conditions preventing maintenance

3. Eliminate potential causes of disease.

4. Begin preventive dentistry activities.

Goals of this phase are to remove etiologic factors and stabilize the patients dental

health.

Example : of control phase treatments include

1. Extractions

2. endodontics

3. Periodontal debridement and scaling

4. Occlusal adjustment

5. Caries removal

6. Replacement or repair of defective restorations

7. Use of caries control measures.

* Prevention and management of caries

Chemical - use of anti microbial agents to alter oval flora and administration of topical

fluoride.

Surgical - Removal of diseased tooth structure and replacement with restorative material

Rehavioral - help the patients develop skills, knowledge and knowledge to alter

deleterious dietary intake and improve oral hygiene

Mechanical - mechanical alteration of tooth structure at high risk (example sealants)

Dietary - alterations of the character of the diet

Other – stimulation of salivary flow through increased chewing, alteration of

medications and use of artificial saliva.

*Re-evaluation phase

The holding phase is a time between control and definitive phases that allows. For

resolution of inflammation and time for healing.

Home care habits are reinforced, motivation for further treatment is assessed, and

initial treatment and pulpal responses are re-evaluated before definitive care is

begun.

* Definitive Phase

This is the corrective phase which includes endodontic, periodontic, orthodontic – oral

surgical and operative procedures before fixed or removable prosthodontic treatment.

All teeth to be restored with large or east restorations should have pulpal / periapical

evaluation.

If indicated they should have endodontic treatment before restoration is completed.

Endodontically treated teeth with no evidence of healing, or has inadequate fill should be

evaluated for retreatment.

Maintenance phase

Regular recall examinations that

1. May reveal the need for adjustments to prevent future breakdown

2. Provide an opportunity to reinforce home care.

3. Frequency of recall examination depends on patients risk for dental disease.

4. Low risk patients -> 9-12 month interval

High risk patients -> 3 – 4 months interval.

CONCLUSION

Proper diagnosis and treatment planning play a critical role in the quality of dental care.

Each patient must be evaluated individually in a through and systematic fashion. After the

patients condition is understood and recorded, a treatment plan canbe developed and rendered.

Examination, diagnosis, and treatment planning are extremely challenging and rewarding

for both the patient and the dentist if done thoroughly and properly with the patients best interest

in mind.

REFERENCES

1. Operative Dentistry (4th edition) By Sturdvent)

2. Endodontics (5th edition) –Ingle and Bekland

3. Pathways of pulp (8th edition) – Cohen and Burns

4. Endodontic Practice – Grossman

5. The dental pulp (3rd edition) Samuel seltzer J.B. Bender

6. Endodontic therapy (4th edition) Wiene

7. Principle and Practice of endodontics – Weltons Torabinejad

8. Color Atlas of Dental Medicine – Endodontology – Rudolf Beer, Baumenn, Kin.

9. Color Atlas of endodontics – William T. Johnson

10. Pickards manual of operative dentistry (8th edition) – Kidds, Smith and Watson

11. Ultra sound real time imaging in differential diagnosis of peri apical lesion – E.Cotti et al

(IEJ. 36, 556-563, 2003)

12. Pulse oximetry a diagnostic instrument in pulp vitality testing – A.K. Munshi, Amitha M.

Hegde (J. Clin. Ped. Dent. 26(2), 141-145, 2002)

13. Laser Doppler Flowmetry measurements of pulpal blood flow and severity of dental

injury – R Enshoff et al (IEJ, 37, 463-467, 2004)

14. Diagnosis of external root resorption using TACT – Nance R.S., Tyndoll D (Endo dent.

Troum 200, (16), 24-28)

15. Quantitative light induced fluorescence (QLF) potential method for dental practitioner –

Roswitha Heinniel – Weltzein (Quint. Int. 2003, 34-38, 181-188)

16. Diagnosis, therapy and prevention of cracked tooth syndrome – Werner Geurtsen et al

(Quint. Int. 2003, 34, 409-417).