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L15 Endodontic Diagnostic Procedures_formatted_text

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Endodontic Examination & Diagnosis[^1]

Note

This document outlines the clinical examination procedures that lead to the diagnosis of conditions affecting the pulp, root canal, and periradicular tissues.

What is a Dentist?

  • The Edinburgh Chronicle - Sept. 15th 1759
    • A “tooth-drawer”
  • Merriam-Webster’s Medical Dictionary 2002
    • A licensed practitioner who is skilled in the prevention, diagnosis, and treatment of diseases, injuries, and malformations of the teeth, jaws and mouth, and who makes and inserts false teeth

A key takeaway from the modern definition is the emphasis on being skilled in both prevention and diagnosis, which are crucial aspects of all dentistry, including endodontics.

The Diagnostic Process[^2]

Diagnosis is only one part of the

Note

This process can be viewed as an information-gathering exercise, much like completing a jigsaw puzzle. Each piece of information is vital; a missing piece can lead to an incomplete or misleading picture (diagnosis).

""

  • History
  • Clinical Examination
  • Tests Results
  • Radiographs
  • Diagnosis & Cause
  • Management Plan
  • Discuss with Patient
  • Written Records

Once the diagnosis has been made, the management options are obvious

Components of Examination and Diagnosis[^3][^4]

Note

A comprehensive endodontic diagnosis requires the assessment and recording of four key components:

  1. The Tooth: Identify the specific tooth with the problem (e.g., tooth 16, 46, 11).
  2. The Pulp/Root Canal State:
    • If a pulp is present, determine its state (e.g., normal, reversible pulpitis, irreversible pulpitis).
    • If no pulp is present, determine the state of the root canal system (e.g., necrotic and infected, pulpless and infected).
  3. The Periapical State: Assess the condition of the periapical or periradicular tissues (e.g., clinically normal, acute apical periodontitis, chronic apical abscess).
  4. The Cause: Identify and record the cause of the problem.

Example Diagnoses:

  • ==Tooth 16 has acute irreversible pulpitis with primary acute apical periodontitis as a result of caries.==
  • ==Tooth 46 has a pulpless infected root canal system with chronic apical periodontitis as a result of breakdown of the restoration and the presence of a crack.==

  • History - past and recent

  • Clinical examination

  • Pulp sensibility and other tests

  • Radiographs

  • Diagnosis

    • Tooth, pulp or root canal status, periapical status
    • Identify the cause

  • Management plan

  • Assess prognosis

The Importance of Identifying the Cause[^5][^6]

  • MUST ALWAYS include an assessment and identification of the CAUSE of the disease so it can be removed

  • Pulp and periapical diseases are usually caused by BACTERIA:

    Must assess how the bacteria have entered the tooth / canal

    Then the appropriate treatment becomes very obvious

  • ==Caries: The carious lesion must be removed.==

  • ==Leaking/Broken-down Restoration: The old restoration must be removed as it provides a pathway for bacteria.==

  • ==Crack: The crack must be removed or managed as it serves as a bacterial conduit.==

History Taking

  • Take a thorough history

Tip

A thorough history is best taken in a non-threatening environment, ideally away from the dental chair. A consultation area with a desk where the dentist and patient can sit face-to-face facilitates better communication, similar to a medical doctor’s consultation room. This is more effective than discussing issues while the patient is in the dental chair, which can be an intimidating environment.

Important Considerations for Pulp and Periapical Diseases[^7]

Dental History

  • Helps establish previous events that may decrease the pulp’s reparative functions - such as:
    • Previous restorations
    • Previous caries, trauma, etc
    • Previous symptoms
    • Previous treatment

History of Pain

  • Clues to help diagnosis
    • Nature of pain
    • Duration of pain
    • Onset of pain
    • Stimuli that cause the pain
    • Relationship to past events (restorations, etc)

Nature of Pain[^8]

  • Duration
    • Seconds, minutes, ? lingering
  • Stimuli that cause the pain
  • ? Spontaneous
  • ? Waking at night
  • ? Worse lying down
  • ? Analgesics required
  • Etc

Diagnostic Clues from Pain Characteristics

  • ==Duration: Does it last for a few seconds (suggesting reversible pulpitis) or linger for minutes to hours (suggesting irreversible pulpitis)?==
  • ==Stimuli:==
    • ==Pain from hot or cold suggests pulpitis.==
    • ==Pain on biting suggests periapical inflammation.==
  • ==Spontaneous Pain: Pain that occurs without a stimulus, wakes the patient at night, or is worse when lying down strongly indicates acute irreversible pulpitis.==
  • ==Analgesics:==
    • ==Severity: The type and frequency of analgesics taken can indicate the pain’s severity. Needing frequent, strong medication (e.g., two ibuprofen every 3-4 hours) suggests severe pain.==
    • ==Coping Mechanisms: It also provides insight into the patient’s individual pain perception and coping ability, which is important for patient management.==

Basis for Diagnosis

  • Detailed history

    • Provisional diagnosis of the disease

  • ==Pulpitis: Suspected if the patient complains of sensitivity to temperature changes. Lingering or spontaneous pain points towards irreversible pulpitis.==

  • ==Apical Periodontitis: Suspected if the patient complains of a dull ache or soreness on biting, suggesting an infected root canal system.==

Note

This provisional diagnosis guides the clinical examination, helping the clinician know what to look for to confirm the diagnosis, the specific tooth involved, and the cause of the problem.

  • Clinical & radiographic examinations
    • Confirm the diagnosis
    • Confirm which tooth
    • Determine the cause

Diagnostic Tests and Procedures[^9]

  • Pulp sensibility tests
    • Cold
    • Heat
    • Electric
  • Percussion
  • Palpation
  • Periodontal probing
  • Mobility
  • Radiographs
    • PA, Tube shifts, BW
  • Transillumination
    • Fibre optic light
  • Biting tests
  • Local anaesthesia
  • Test cavity

Function of Diagnostic Tests[^10]

  • Pulp sensibility tests (Cold, Heat, Electric)
    • Indicate Pulp / Root Canal Status
  • Percussion & Palpation
    • Indicate Periapical Status
  • Periodontal probing & Mobility
    • Indicate Periodontal Status
  • Radiographs (PA, Tube shifts, BW)
    • Indicate Periapical + Periodontal Status & Possible Cause(s)
  • Transillumination (Fibre optic light) & Biting tests
    • Indicate Possible Cause(s)
  • Local anaesthesia
    • LA Not Usually Necessary or Helpful for Acute Pain

They are rarely used and often unreliable for pinpointing a single tooth, especially with block anesthesia. They may occasionally be used for chronic, difficult-to-diagnose pain.

  • Test cavity
    • A Barbaric Pulp Sensibility Test !!! Not Required !!! Not Recommended !!!

It involves drilling into an unanesthetized tooth to check for a response, which provides the same information as a standard pulp sensibility test but erodes patient confidence.

Reliability of Diagnostic Tests[^11]

  • Q. Which diagnostic test is the most reliable for endodontic diagnosis?
  • A. There is NOT ONE single test -
    • Need AT LEAST TWO symptoms or signs to confirm the disease
    • Preferably more than two symptoms / signs

Pulp Sensibility Tests[^12]

  • Thermal and electric pulp tests are “Sensibility Tests”

Info

These tests assess the sensibility of the pulp—its ability to respond to a stimulus. They are not

Cold Tests

  • CO₂
  • Ice
  • Cold Sprays
  • Cold H₂O

Details on Cold Test Methods

  • ==CO₂ Snow (Dry Ice): The best and most reliable cold test. A pencil of dry ice (approx. -70°C) is produced and applied to the tooth. It is very cold and allows for rapid testing of multiple teeth.==
  • ==Refrigerant Sprays: Sprayed onto a cotton pellet. They are less cold than CO2 and can become liquid quickly, potentially running onto the gingiva and causing a false positive response.==
  • ==Ice Sticks: Often made by freezing water in a local anesthetic cartridge. They melt rapidly, and the water can run onto adjacent tissues, making the response difficult to interpret.==
  • ==Cold Water Syringe: Used on a tooth isolated with a rubber dam. Not ideal as the water is not particularly cold.==

Heat Tests[^13]

Warning

Heat tests are used infrequently, typically only if a patient’s sole complaint is heat sensitivity (which is rare). They are difficult to control and potentially dangerous.

  • Heat
  • Hot H₂O

(Syringe is used on a tooth isolated with a rubber dam. Fiddly to perform.)

  • No control of the temperature with any of these heat tests

  • ==Heated Ball Burnisher: A large metal ball burnisher is heated until red-hot and held a few millimeters from the tooth to radiate heat. Surrounding tissues must be carefully protected.==

  • ==Heated Gutta-Percha: A stick of gutta-percha is heated and applied to the tooth. Requires careful isolation.==

  • ==Rubber Cup Friction: A rubber cup in a low-speed handpiece is run on the tooth to generate frictional heat. The patient may confuse the vibration with a heat response.==

Electric Pulp Tests[^14]

Note

An EPT device passes an increasing electric current through the tooth.

  • ==Procedure: A conductive medium (e.g., toothpaste) is placed on the probe tip. The circuit is completed by the clinician touching the patient while holding a metal handle on the device. The patient signals when they feel a tingling sensation.==
  • ==Interpretation: The primary value is determining if there is a response (vital pulp) or no response (necrotic pulp). The numerical readout is arbitrary and not a reliable measure of pulp health, but it provides a data point.==

Radiographic Examination[^23]

Periapical Radiographs

Info

These are the most important radiographs for endodontic diagnosis as they show the entire root and periapical tissues. Careful examination can reveal:

  • Caries (especially under restorations)
  • Depth of restorations
  • Furcation involvement
  • Calculus
  • Periapical radiolucencies (indicating bone loss)
  • Widening of the PDL space (an early sign of inflammation or a crack)
  • Condensing osteitis (dense bone, indicating long-standing chronic inflammation)
  • Gutta percha point placed in a draining sinus
    • Periapical radiograph exposed
    • Traces the origin of the draining sinus

, which may be several teeth away from the sinus opening.

Bitewing Radiographs[^24][^25]

Info

Bitewings are useful for assessing:

  • Interproximal caries
  • The relationship of restorations to the pulp chamber
  • Crestal bone levels
  • Pulp Canal Calcification
  • Periodontal Disease
  • Caries
  • ALSO: Invasive resorption

Panoramic Radiographs

  • General “screening” of teeth and jaws -
  • **but insufficient detail for endodontic diagnosis

It provides a general overview and helps identify areas that require further investigation with periapical radiographs and clinical tests.

**

Additional Diagnostic Aids[^26]

Fibre-optic light transillumination

This is a highly valuable tool for detecting cracks that are not visible under normal light.

  • ==Principle: A powerful, focused light is shone through the tooth. A crack will block or deflect the light rays, appearing as a dark line.==
  • ==Technique: The light should be moved around the entire tooth, shining from buccal, lingual, and occlusal/incisal directions to reveal cracks from all angles.==
  • NSK
  • Quality Aspirators
  • Novar Demetron
  • Microlux

Magnification[^27][^28][^29][^30][^31]

Note

Using dental loupes or a surgical microscope can help make subtle details, such as cracks or caries, more visible.

Pain on Biting / Chewing

  • Possible Causes:
    • Cusp flexure
      • → Crack(s)
    • Apical periodontitis
      • → Infected canal
    • Lateral periodontitis
      • → Crack
      • → Periodontal disease

Tests for Pain on Biting[^32]

  • Tooth Slooth
  • FracFinder

Technique

The instrument is placed on one cusp at a time. The patient is asked to bite down firmly, and the clinician may gently wiggle the instrument to simulate chewing forces. A sharp pain upon biting or, more commonly, upon release of pressure, is highly indicative of a crack undermining that cusp.

Synthesizing the Diagnosis[^33]

  • The history
  • Exam findings, tests, radiographs, etc
  • The DIAGNOSIS
  • Which TOOTH, and
  • The CAUSE = Determine the MANAGEMENT OPTIONS & help to assess the PROGNOSIS

Flow Chart for Diagnosing Common Pulp and Periapical Diseases

Four things to consider and assess:

  1. Identify the TOOTH to be diagnosed
  2. Assess the status of the PULP
    • Or if NO pulp present, then assess the status of the ROOT CANAL SYSTEM
  3. Assess the status of the PERIAPICAL TISSUES
  4. Determine the CAUSE(S) of the disease(s)

Initial Assessment: Pulpitis or Infected Canal?[^34]

  • Pulpitis Side: Characterized by thermal symptoms, sharp pain.
  • Infected Canal Side: Characterized by an ache, pain to bite &/or chew.

Diagnostic Pathway: Pulpitis[^35]

  1. Pulpitis
  2. Assess Pulpitis Type:
    • Reversible Pulpitis: Extreme temperature changes, short duration.
    • Irreversible Pulpitis: Mild temperature change, Lingering, Spontaneous, short + sharp, aches afterwards.
  3. Assess Acuity:
    • Acute: More severe pain, short time present (? days), most common.
    • Chronic: Mild pain, present for long time (? weeks, months).
  4. Assess Periapical Involvement:
    • Apical Periodontitis also?
      • Signs: Pain to biting &/or chewing, tenderness to percussion, radiographic changes.
    • If so, Acute or Chronic?
      • Based on time present (? days, weeks, months).

Diagnostic Pathway: Infected Canal[^36]

  1. **Infected canal

Info

In all cases, there will be no response to pulp sensibility tests.

** 2. Assess Root Canal Condition: - Necrotic & Infected? - No response to Pulp Tests, recent problem, no periapical radiographic changes. - Pulpless & Infected? - No response to Pulp Tests, problem present for longer period of time, periapical radiolucency present. - Previous Endodontic treatment & Infected? - History or radiographic signs of previous treatment; periapical radiolucency present.

Radiographic Correlation for Infected Canals

The radiograph is key to distinguishing between a necrotic pulp and a pulpless system.

  • ==Necrotic and Infected Pulp: No periapical radiolucency is visible on the radiograph.==
  • ==Pulpless and Infected Root Canal System: A periapical radiolucency is present, indicating the infection has been established for some time.==
  1. Assess Periapical Condition:
    • Apical periodontitis?
      • Pain to bite &/or chew, tender to percussion.

Inflammation without pus formation. There is no swelling.

- **Apical Abscess?**
  - Localised collection of pus, swelling, fever, etc.

There is swelling, which may be fluctuant.

- **Facial Cellulitis?**
  - Spreading infection through face, pus, swelling, fever, etc.

A severe, spreading infection throughout the facial tissues. The patient’s face is visibly swollen, and they often feel systemically unwell (malaise, fever). This is always an acute condition.

  1. Assess Acuity (Acute or Chronic?):
    • Except if Facial Cellulitis
    • Acute: Pain, short time present (? days).
    • Chronic: Nil or mild pain, present for long time (? weeks, months), draining sinus if apical abscess.

The presence of a draining sinus is a definitive sign of a chronic apical abscess.

  1. Assess Origin (Primary or Secondary?):
    • Except if Facial Cellulitis

Radiographic Correlation for Infected Canals[^37][^38]

  • No radiolucency or slight thickening of PDL → Can be Apical Periodontitis, Apical Abscess, or Facial Cellulitis.
  • Periapical radiolucency present → Can be Apical Periodontitis, Apical Abscess, or Facial Cellulitis.

Diagnostic Flowchart for Pulpal and Periapical Diseases

graph TD
    I[1. **Pulpitis** or an **Infected canal** ?] --> J(2 A. Reversible Pulpitis ? or Irreversible Pulpitis ?);
    J --> K(2 B. Acute or Chronic ?);
    K --> L(2 C. Apical Periodontitis also ?);
    L --> M(2 D. If so, Acute or Chronic ?);
    I --> N(3 A. Root Canal Condition);
    N --> O(3 B. Necrotic & Infected ? or Pulpless & Infected ? or Previous Endodontic treatment & Infected ?);
    I --> P(4 A. Periapical Condition);
    O --> Q(4 B. Apical periodontitis ? or Apical Abscess ? or Facial Cellulitis ?);
    P --> Q;
    Q --> R(4 C. Acute or Chronic ? (except if Facial Cellulitis));
    R --> S(4 D. Primary or Secondary ? (except if Facial Cellulitis));
    
    style I fill:#000,stroke:#f00,color:#fff
    style J fill:#ffd700,stroke:#000,color:#000
    style K fill:#ffd700,stroke:#000,color:#000
    style L fill:#ffd700,stroke:#000,color:#000
    style M fill:#ffd700,stroke:#000,color:#000
    style N fill:#ffd700,stroke:#000,color:#000
    style P fill:#ffd700,stroke:#000,color:#000
    style O fill:#ffd700,stroke:#000,color:#000
    style Q fill:#ffd700,stroke:#000,color:#000
    style R fill:#ffd700,stroke:#000,color:#000
    style S fill:#ffd700,stroke:#000,color:#000
``

> [!info] This distinction applies only to **acute** apical periodontitis and **acute** apical abscesses.
> 
> - ==**Primary Acute:** There is **no pre-existing radiolucency** on the radiograph (or only a slight widening of the PDL). This indicates a rapid, new infection.==
> - ==**Secondary Acute (or

`

[^1]: Original PDF page 1: [[L15 Endodontic Diagnostic Procedures.pdf#page=1|L15 Endodontic Diagnostic Procedures, p.1]]
[^2]: Original PDF page 2: [[L15 Endodontic Diagnostic Procedures.pdf#page=2|L15 Endodontic Diagnostic Procedures, p.2]]
[^3]: Original PDF page 3: [[L15 Endodontic Diagnostic Procedures.pdf#page=3|L15 Endodontic Diagnostic Procedures, p.3]]
[^4]: Original PDF page 4: [[L15 Endodontic Diagnostic Procedures.pdf#page=4|L15 Endodontic Diagnostic Procedures, p.4]]
[^5]: Original PDF page 5: [[L15 Endodontic Diagnostic Procedures.pdf#page=5|L15 Endodontic Diagnostic Procedures, p.5]]
[^6]: Original PDF page 6: [[L15 Endodontic Diagnostic Procedures.pdf#page=6|L15 Endodontic Diagnostic Procedures, p.6]]
[^7]: Original PDF page 7: [[L15 Endodontic Diagnostic Procedures.pdf#page=7|L15 Endodontic Diagnostic Procedures, p.7]]
[^8]: Original PDF page 8: [[L15 Endodontic Diagnostic Procedures.pdf#page=8|L15 Endodontic Diagnostic Procedures, p.8]]
[^9]: Original PDF page 9: [[L15 Endodontic Diagnostic Procedures.pdf#page=9|L15 Endodontic Diagnostic Procedures, p.9]]
[^10]: Original PDF page 10: [[L15 Endodontic Diagnostic Procedures.pdf#page=10|L15 Endodontic Diagnostic Procedures, p.10]]
[^11]: Original PDF page 11: [[L15 Endodontic Diagnostic Procedures.pdf#page=11|L15 Endodontic Diagnostic Procedures, p.11]]
[^12]: Original PDF page 12: [[L15 Endodontic Diagnostic Procedures.pdf#page=12|L15 Endodontic Diagnostic Procedures, p.12]]
[^13]: Original PDF page 13: [[L15 Endodontic Diagnostic Procedures.pdf#page=13|L15 Endodontic Diagnostic Procedures, p.13]]
[^14]: Original PDF page 14: [[L15 Endodontic Diagnostic Procedures.pdf#page=14|L15 Endodontic Diagnostic Procedures, p.14]]
[^23]: Original PDF page 23: [[L15 Endodontic Diagnostic Procedures.pdf#page=23|L15 Endodontic Diagnostic Procedures, p.23]]
[^24]: Original PDF page 24: [[L15 Endodontic Diagnostic Procedures.pdf#page=24|L15 Endodontic Diagnostic Procedures, p.24]]
[^25]: Original PDF page 25: [[L15 Endodontic Diagnostic Procedures.pdf#page=25|L15 Endodontic Diagnostic Procedures, p.25]]
[^26]: Original PDF page 26: [[L15 Endodontic Diagnostic Procedures.pdf#page=26|L15 Endodontic Diagnostic Procedures, p.26]]
[^27]: Original PDF page 27: [[L15 Endodontic Diagnostic Procedures.pdf#page=27|L15 Endodontic Diagnostic Procedures, p.27]]
[^28]: Original PDF page 28: [[L15 Endodontic Diagnostic Procedures.pdf#page=28|L15 Endodontic Diagnostic Procedures, p.28]]
[^29]: Original PDF page 29: [[L15 Endodontic Diagnostic Procedures.pdf#page=29|L15 Endodontic Diagnostic Procedures, p.29]]
[^30]: Original PDF page 30: [[L15 Endodontic Diagnostic Procedures.pdf#page=30|L15 Endodontic Diagnostic Procedures, p.30]]
[^31]: Original PDF page 31: [[L15 Endodontic Diagnostic Procedures.pdf#page=31|L15 Endodontic Diagnostic Procedures, p.31]]
[^32]: Original PDF page 32: [[L15 Endodontic Diagnostic Procedures.pdf#page=32|L15 Endodontic Diagnostic Procedures, p.32]]
[^33]: Original PDF page 33: [[L15 Endodontic Diagnostic Procedures.pdf#page=33|L15 Endodontic Diagnostic Procedures, p.33]]
[^34]: Original PDF page 34: [[L15 Endodontic Diagnostic Procedures.pdf#page=34|L15 Endodontic Diagnostic Procedures, p.34]]
[^35]: Original PDF page 35: [[L15 Endodontic Diagnostic Procedures.pdf#page=35|L15 Endodontic Diagnostic Procedures, p.35]]
[^36]: Original PDF page 36: [[L15 Endodontic Diagnostic Procedures.pdf#page=36|L15 Endodontic Diagnostic Procedures, p.36]]
[^37]: Original PDF page 37: [[L15 Endodontic Diagnostic Procedures.pdf#page=37|L15 Endodontic Diagnostic Procedures, p.37]]
[^38]: Original PDF page 38: [[L15 Endodontic Diagnostic Procedures.pdf#page=38|L15 Endodontic Diagnostic Procedures, p.38]]

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