Diagnostic procedures

• Diagnosis is the art and science of determining the disease process by systematically collecting and recording facts, and carefully analyzing and integrating these facts
• Developing data/patient history includes:

  • Chief complaint: reason why the patient visited the dentist, written in the patient's own words
  • History of Present Illness: facts gathered through thorough interview and questioning
  • Symptoms: signs indicative of illness, subjective symptoms experienced by the patient, and objective symptoms gathered using various tests
• Pain is the most common symptom that leads to dental consultation and treatment, and includes:

  • Location: localized, diffused, radiating, referred
  • Quality: sharp, piercing, dull
  • Onset: spontaneous, provoked
  • Provoking factor: cold, heat, biting, sweets
  • Alleviating factor: cold, heat
  • Intensity: mild, moderate, severe
  • Duration: constant, momentary, intermittent
  • Primary source of pain: pulp, periodontal ligament
  • Referred pain: adjacent, opposing tooth, non-odontogenic in nature, organic cause (emotional, systemic)
• Medical History/vital signs include:

  • Past and present systemic illnesses (health status)
  • Medications taken
  • Allergic response to medicaments
  • Family history
  • Vital signs: body temperature, pulse rate, respiratory rate, blood pressure
• Clinical Examination includes:

  • Extraoral Examination: gait or balance, facial asymmetry, eyes, alertness, skin, mandibular range of motion, cervical/submandibular lymph nodes, masticatory muscles, temporomandibular joints
  • Intraoral Examination: caries & defective restorations, toothbrush abrasion, discolored teeth & fractured teeth, observable swelling/sinus opening, consistency & color of the oral mucosa
• Radiographic Examination:

  • Very useful tool in diagnosis
  • 2-dimensional image of a 3-dimensional structure
  • Good illumination and magnification needed for interpretation
  • Various views from multiple angles needed to capture more of the 3-dimensional image
  • What to look for: continuity of the lamina dura, width of the periodontal space, evidence of demineralization in the bony architecture, condition of the root canal system, resorptions and calcifications, anatomic landmarks, presence of extra roots/canals, immature root apices, tooth/root fractures, gutta percha tracing
• Diagnostic Tests:

  • Do more than one endodontic diagnostic test
  • Do tests on at least three teeth: involved tooth, adjacent tooth, contralateral tooth
  • Vitality tests include Thermal Pulp Testing (Heat Test, Cold Test, Electric Pulp Tester)
  • Responses to thermal tests: no response, false negative response, within normal limits, reversible pulpitis, irreversible pulpitis
  • Electric pulp testing: test for vital sensory fibers, does not provide information about the health & integrity of the pulp
• • Percussion Test: shows if the periodontal inflammation has reached the periosteum, does not give information about the status of the pulp
  • Periodontal Probing Depths: essential in distinguishing between disease of periodontal origin from disease of pulpal origin
  • Special Tests include Selective anesthesia, Test cavity, Transillumination, Wedging and staining for detection of cracked teeth
• The dentist/clinician must be able to analyze and synthesize the gathered results to arrive at a correct diagnosis, ensuring the correct choice of treatment and good case prognosis
• Examination procedures required to make an endodontic diagnosis include:

  • Medical/dental history: past/recent treatment, drugs, chief complaint (if any)
  • Clinical exam: facial symmetry, sinus tract, soft tissue, periodontal status (probing, mobility), caries, restorations
  • Clinical testing: pulp tests (cold, electric pulp test, heat), periapical tests (percussion, palpation, Tooth Slooth biting)
  • Radiographic analysis: new periapicals (at least 2), bitewing, cone beam-computed tomography
  • Additional tests: transillumination, selective anesthesia, test cavity
• Diagnostic classification systems for endodontic disease have historically been based on histopathological findings, leading to confusion and incorrect diagnoses
• Establishing a proper pulpal and periapical diagnosis is crucial to determine the needed clinical treatment
• A universal classification system in endodontics allows for communication between educators, clinicians, students, and researchers
• In 2008, the American Association of Endodontists held a consensus conference to standardize diagnostic terms used in endodontics
• Diagnostic terminology approved by the American Association of Endodontists and the American Board of Endodontics includes:

  • Normal Pulp
  • Reversible Pulpitis
  • Symptomatic Irreversible Pulpitis
  • Asymptomatic Irreversible Pulpitis
  • Pulp Necrosis
  • Previously Treated
  • Previously Initiated Therapy
  • Normal Apical Tissues
  • Symptomatic Apical Periodontitis
  • Asymptomatic Apical Periodontitis
  • Chronic Apical Abscess
• Endodontic diagnosis is similar to a jigsaw puzzle, requiring systematic gathering of information for a probable diagnosis
• Treatment should not be rendered without a proper diagnosis, and inconclusive results may require reassessment or referral to an endodontist
• Chronic Apical Abscess:

  • Inflammatory reaction to pulpal infection and necrosis
  • Characterized by gradual onset, little or no discomfort, and intermittent discharge of pus through an associated sinus tract
  • Radiographically shows signs of osseous destruction such as a radiolucency
  • To identify the source of a draining sinus tract, a gutta-percha cone is placed through the stoma or opening until it stops and a radiograph is taken
• Acute Apical Abscess:

  • Inflammatory reaction to pulpal infection and necrosis
  • Characterized by rapid onset, spontaneous pain, extreme tenderness of the tooth to pressure, pus formation, and swelling of associated tissues
  • May not show radiographic signs of destruction
  • Patient may experience malaise, fever, and lymphadenopathy
• Condensing Osteitis:

  • Diffuse radiopaque lesion representing a localized bony reaction to a low-grade inflammatory stimulus
  • Usually seen at the apex of the tooth
• • Maxillary left lateral incisor: Pulp necrosis; asymptomatic apical periodontitis
• Diagnostic Case Examples:

  • Mandibular right first molar: Pulp necrosis; symptomatic apical periodontitis with condensing osteitis
  • Maxillary right second molar: Symptomatic irreversible pulpitis; normal apical tissues
  • Maxillary left first molar: Reversible pulpitis; normal apical tissues
  • Mandibular right lateral incisor: Pulp necrosis; asymptomatic apical periodontitis
  • Mandibular left first molar: Pulp necrosis; chronic apical abscess
  • Maxillary left first molar: Previously treated; symptomatic apical periodontitis