Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Endodontic Examination**
**& Diagnosis**
**Prof. Paul V. Abbott AO**
BDSc, MDS, DDSc, FRACDS(Endo), FPFA, FADI, FICD, FACD, FIADT
1
**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
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2$^{nd}$ Year DMD - 2023 Page 1
# **Endodontic Examination & Diagnosis**
> [!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
> [!info] 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.
Endodontic Diagnostic Procedures
Diagnosis is only one part of
the "**$\underline{Diagnostic\ Process}$**"
**The Diagnostic Process**
* History
* Clinical Examination
* Tests Results
* Radiographs
* Diagnosis & Cause
* Management Plan
* Discuss with Patient
* Written Records
$\text{2}^\text{nd}\text{ Year DMD - 2023}$
W/Prof. Paul V. Abbott AO
Page 2
# **The Diagnostic Process**
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).
"**$\underline{Diagnostic\ Process}$**"
- History
- Clinical Examination
- Tests Results
- Radiographs
- Diagnosis & Cause
- Management Plan
- Discuss with Patient
- Written Records
![]()
Jigsaw puzzle metaphor with incomplete and complete image of Fremantle Maritime Museum
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**The Diagnostic Process**
M **History**
M **Clinical Examination**
M **Tests Results**
M **Radiographs**
M **Diagnosis & Cause**
M **Management Plan**
M **Discuss with Patient**
M **Written Records**
Once the diagnosis has been made, the management options are obvious
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**Examination and Diagnosis**
* **History - past and recent**
* **Clinical examination**
* **Pulp sensibility and other tests**
* **Radiographs**
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$2^{\text{nd}}$ Year DMD - 2023 Page 4
Once the diagnosis has been made, the management options are obvious
# **Components of Examination and Diagnosis**
> [!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] 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
Endodontic Diagnostic Procedures
W/Prof. Paul V. Abbott AO
<br>
# **Examination and Diagnosis**
* **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`
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<br>
# **Examination and Diagnosis**
* **MUST ALWAYS include an assessment and identification of the CAUSE of the disease so it can be removed**
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<br>
2nd Year DMD - 2023
Page 5
- `Diagnosis`
- Tooth, pulp or root canal status, periapical status
- Identify the cause
- `Management plan`
- `Assess prognosis`
## **The Importance of Identifying the Cause**
- **MUST ALWAYS include an assessment and identification of the CAUSE of the disease so it can be removed**
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Examination and Diagnosis**
% **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
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**Examination and Diagnosis**
* Take a thorough history
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2nd Year DMD - 2023 Page 6
- **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.
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Pulp and Periapical Diseases**
**Important Considerations:**
M **Dental history**
* Helps establish previous events that may decrease the pulp’s reparative functions - such as:
x Previous restorations
x Previous caries, trauma, etc
x Previous symptoms
x Previous treatment
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**Pulp and Periapical Diseases**
**Important Considerations:**
M **History of Pain**
* **Clues to help diagnosis**
x Nature of pain
x Duration of pain
x Onset of pain
x Stimuli that cause the pain
x Relationship to past events (restorations, etc)
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2nd Year DMD - 2023 Page 7
## **Important Considerations for Pulp and Periapical Diseases**
### **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)
Endodontic Diagnostic Procedures
Pulp and Periapical Diseases
**Important Considerations:**
<br>
× **Nature of Pain**
<br>
° Duration
<br>
× Seconds, minutes, ? lingering
° Stimuli that cause the pain
° ? Spontaneous
° ? Waking at night
° ? Worse lying down
° ? Analgesics required
° Etc
<br>
<br>
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<br>
Pulp and Periapical Diseases
**Diagnosis must be based on:**
<br>
<br>
× Detailed history
<br>
° Provisional diagnosis of the disease
<br>
<br>
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<br>
W/Prof. Paul V. Abbott AO
Page 8
$2^{\text{nd}}$ Year DMD - 2023
### **Nature of Pain**
- Duration
- Seconds, minutes, ? lingering
- Stimuli that cause the pain
- ? Spontaneous
- ? Waking at night
- ? Worse lying down
- ? Analgesics required
- Etc
> [!info] 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.
**Endodontic Diagnostic Procedures** W/Prof. Paul V. Abbott AO
**Pulp and Periapical Diseases**
**Diagnosis must be based on:**
* **Detailed history**
* **Provisional diagnosis of the disease**
* **Clinical & radiographic examinations**
* **Confirm the diagnosis**
* **Confirm which tooth**
* **Determine the cause**
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**Endodontic Examination**
**Diagnostic Tests**
* **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**
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2$\text{nd}$ Year DMD - 2023
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- **Clinical & radiographic examinations**
- **Confirm the diagnosis**
- **Confirm which tooth**
- **Determine the cause**
# **Diagnostic Tests and Procedures**
- **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**
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Endodontic Examination**
**Diagnostic Tests**
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```mermaid
flowchart TD
A[Pulp sensibility tests] --> B[Indicate Pulp / Root Canal Status]
A --> C{Cold}
A --> D{Heat}
A --> E{Electric}
F[Percussion] --> G[Indicate Periapical Status]
H[Palpation] --> G
I[Periodontal probing] --> J[Indicate Periodontal Status]
K[Mobility] --> J
```
**Endodontic Examination**
**Diagnostic Tests**
```mermaid
flowchart TD
A[Radiographs] --> B[Indicate Periapical + Periodontal Status & Possible Cause(s)]
A --> C{PA, Tube shifts, BW}
D[Transillumination] --> E[Indicate Possible Cause(s)]
D --> F{Fibre optic light}
G[Biting tests] --> E
G --> H[LA Not Usually Necessary or Helpful for Acute Pain]
I[Local anaesthesia] --> H
J[Test cavity] --> K[A Barbaric Pulp Sensibility Test !!! Not Required !!! Not Recommended !!!]
```
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$2^{nd}$ Year DMD - 2023 Page 10
## **Function of Diagnostic Tests**
- **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.
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Pulp and Periapical Diseases**
**Diagnostic Tests**
Q. Which diagnostic test is the most
reliable for endodontic diagnosis?
| Pulp sensibility tests | Radiographs |
| :---: | :---: |
| - Cold | - PA, Tube shifts, BW |
| - Heat | Transillumination |
| - Electric | - Fibre optic light |
| Palpation | Biting test |
| Percussion | - Tooth Slooth |
| Mobility | Local anaesthesia |
| Periodontal probing | Test cavity |
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**Pulp and Periapical Diseases**
**Diagnostic Tests**
Q. Which diagnostic test is the most
reliable for endodontic diagnosis?
A. There is **NOT ONE** single test -
ñ Need **AT LEAST TWO** symptoms
or signs to confirm the disease
ñ Preferably more than two symptoms / signs
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2nd Year DMD - 2023 Page 11
## **Reliability of Diagnostic Tests**
- **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
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**M Thermal and electric pulp tests are**
**“Sensibility Tests”**
CO₂
23
→ **Cold Tests**
CO₂
Ice
Cold Sprays
Cold H₂O
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## **Pulp Sensibility Tests**
- 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
> [!info] 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.==
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Heat Tests**
Heat
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**Heat Tests**
No control of the temperature with any of these heat tests
**Hot H₂O**
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2ⁿd Year DMD - 2023 Page 13
### **Heat Tests**
> [!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.==
**Endodontic Diagnostic Procedures**
W/Prof. Paul V. Abbott AO
Page 14
2nd Year DMD - 2023
**Electric Pulp Tests**
<img src="images/Electric_Pulp_Test_Devices.png" alt="Devices used for electric pulp tests, including a power unit and a probe applied to a tooth.">
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%
Thermal and electric pulp tests are
“Sensibility Tests”
<img src="images/Sensibility_Tests_CO2_Heat_Electric.png" alt="Images showing testing in patient's mouth: CO2 application to a tooth, a device for Heat test, and Electric pulp test application.">
CO2
Electric
Heat
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### **Electric Pulp Tests**
> [!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.==
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Thermal and electric pulp tests are**
**"Sensibility Tests"**
**When testing for necrosis**
* **Sensibility:**
* **Ability to respond to a stimulus**
* **Note: NOT “Sensitivity”**
* **Sensitivity is a condition of being very responsive to a stimulus**
**When testing for pulpitis**
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**Pulp and Periapical Diseases**
**Diagnostic Tests**
| Group 1 | Tests | Group 2 | Tests |
|---|---|---|---|
| M | **Pulp sensibility tests** | M | **Radiographs** |
| | ° Cold | | ° PA, Tube shifts, BW |
| | ° Heat | M | **Transillumination** |
| | ° Electric | | ° Fibre optic light |
| M | **Palpation** | M | **Biting test** |
| M | **Percussion** | | ° Tooth Slooth |
| M | **Mobility** | M | **Local anaesthesia** |
| M | **Periodontal probing** | **9** | **Test cavity** |
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Endodontic Diagnostic Procedures
W/Prof. Paul V. Abbott AO
**Endodontic Examination**
**M** Percussion and Palpation
* **Tests for periapical involvement**
* **Indicate periapical inflammation**
* BUT not very reliable for chronic apical inflammation
* **ALSO need periapical radiographs**
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**Percussion Test**
* **"Normal"** - same as the other teeth, no tenderness
* Typically indicates clinically normal peri-radicular tissues
* **"Tender"** - painful response on percussion
* Typically indicates $2^{\circ}$ acute apical periodontitis or a $2^{\circ}$ acute apical abscess
* **"Very Tender"** - very painful response on percussion
* Typically indicates $1^{\circ}$ acute apical periodontitis or a $1^{\circ}$ acute apical abscess
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Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Percussion Test**
* **"Different sensation"** - the patient says it feels **"different"** on percussion compared to adjacent teeth; not painful or tender
* Typically indicates chronic apical periodontitis or a chronic apical abscess
* **"Ankylosis"** - no pain; dull sound; sounds different to adjacent teeth; usually decreased mobility
* Indicates the tooth has ankylosis
* May also have external replacement resorption (or possibly other forms of resorption)
* A detailed history should help to determine why there is ankylosis
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**Palpation Test**
* **"Normal"** - same as the other teeth, no tenderness
* Typically indicates clinically normal peri-radicular tissues
* **"Tender"** - painful when palpating mucosa overlying the tooth root
* Typically indicates $2^{\circ}$ acute apical periodontitis or a $2^{\circ}$ acute apical abscess
* **"Very Tender"** - very painful when palpating mucosa overlying the tooth root
* Typically indicates $1^{\circ}$ acute apical periodontitis or a $1^{\circ}$ acute apical abscess
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$2^{\text {nd }}$ Year DMD - 2023 Page 17
Endodontic Diagnostic Procedures
W/Prof. Paul V. Abbott AO
# <font color="#f7da00">Palpation Test</font>
* **“Hard swelling or expansion”** - tissues overlying the
root look swollen; or the cortical plate has expanded
* <font color="#83ff00">Typically indicates chronic apical periodontitis</font>
* **“Soft swelling”** - tissues overlying the root are
swollen and feel soft on palpation
* <font color="#83ff00">Typically indicates 1° or 2° acute apical abscess</font>
* **“Soft fluctuant swelling”** - tissues overlying the root
are swollen, soft and fluctuant
* <font color="#83ff00">Typically indicates 1° or 2° acute apical abscess</font>
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# <font color="#f7da00">Endodontic Examination</font>
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2nd Year DMD **-** 2023
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![]()
A clinical photograph showing an area of swelling and a draining sinus on the gingiva in the anterior mandible, indicated by green arrows.
![]()
Illustration showing correct and incorrect techniques for endodontic examination and periodontal probing.
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
Page 20
**Endodontic Examination**
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**Endodontic Examination**
**“Complete”**
**periodontal probing**
Stepwise around the entire
circumference of the tooth
- During the examination
- **After restoration removed**
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2nd Year DMD - 2023 Page 20
![]()
A line drawing illustrating periodontal probing on a tooth in both a buccal view and an occlusal view.
![]()
A line drawing illustrating periodontal probing on a tooth in a buccal view, with text overlay.
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Endodontic Examination**
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**Endodontic Examination**
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2nd Year DMD - 2023
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![]()
Image of a dental probe being used near the gumline of two teeth.
![]()
Image of a dental probe being used near the gumline of two teeth, with a smaller inset showing a wider view.
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Endodontic Examination**
<img src="An image showing probing a tooth with a periodontal probe (indicated by a green arrow) during an endodontic examination."> </img>
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**Endodontic Examination**
<img src="An image showing a diagram of a tooth with multiple canals instrumented, alongside clinical images of probing."> </img>
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Endodontic Diagnostic Procedures
W/Prof. Paul V. Abbott AO
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2nd Year DMD - 2023
**Endodontic Examination**
45
**Periapical Radiographs**
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![]()
An image showing an intraoral view of teeth with large restorations.
![]()
An image showing a periapical radiograph with red arrows pointing to various areas of the teeth and supporting structures.
## **Radiographic Examination**
### **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)==
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Periapical Radiographs**
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**Periapical Radiographs**
Gutta percha point placed in a draining sinus
- **Periapical radiograph exposed**
- Traces the origin of the draining sinus
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2$^{\text{nd}}$ Year DMD - 2023 Page 24
![]()
Periapical radiograph with arrows pointing to the periapical regions of two teeth.
![]()
Clinical image showing a gutta percha point in a draining sinus next to a periapical radiograph with the gutta percha point tracing the sinus tract.
- 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.
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
# **Bitewing Radiographs**
**Pulp Canal Calcification**
**Periodontal Disease**
**Caries**
**ALSO: Invasive resorption**
49
# **Panoramic Radiographs**
**General “screening” of teeth and jaws -**
**but insufficient detail for endodontic diagnosis**
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### **Bitewing Radiographs**
> [!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.
**
Endodontic Diagnostic Procedures
W/Prof. Paul V. Abbott AO
**Fibre-optic light transillumination**
51
**Fibre-optic light transillumination**
NSK
Quality Aspirators
Novar Demetron
Microlux
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## **Additional Diagnostic Aids**
### **Fibre-optic light transillumination**
> [!tip] 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
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Fibre-optic light transillumination**
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**Fibre-optic light transillumination**
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$2^{nd}$ Year DMD - 2023 Page 27
![]()
Image of a tooth before and after transillumination.
![]()
Image of a molar tooth before and after transillumination.
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Fibre-optic light transillumination**
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**Fibre-optic light transillumination**
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$2^{nd}$ Year DMD - 2023 Page 28
![]()
A tooth image showing fibre-optic light transillumination
![]()
A tooth image and a zoomed-in image showing fibre-optic light transillumination with arrows indicating direction
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Fibre-optic light transillumination**
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<img alt="Two images displaying light shining through a tooth, the second image has arrows pointing to a line that is visible because of the light" />
**Fibre-optic light transillumination**
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Endodontic Diagnostic Procedures
W/Prof. Paul V. Abbott AO
**Fibre-optic light transillumination**
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**Fibre-optic light transillumination**
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2nd Year DMD - 2023
Page 30
![]()
An image showing the process of fibre-optic light transillumination on a tooth, illustrating how cracks are revealed by the light.
![]()
An image illustrating fibre-optic light transillumination on a diagrammatic cross-section of a tooth and the resulting light pattern in an actual tooth segment.
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott **AO**
**Magnification**
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Endodontic Examination
**If pain on biting / chewing**
***Possible Causes:***
* Cusp flexure
$\kern{0.3em}$ $\to$ Crack(s)
* Apical periodontitis
$\kern{0.3em}$ $\to$ Infected canal
* Lateral periodontitis
$\kern{0.3em}$ $\to$ Crack
$\kern{0.3em}$ $\to$ Periodontal disease
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$2^{\text{nd}}$ Year DMD - 2023 Page 31
### **Magnification**
> [!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
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
63
# <span style="color:yellow">Tests for Pain on Biting</span>
* Tooth Slooth
* FracFinder
<img_Tooth Slooth with an arrow pointing to the biting surface of the plastic tip._>
# <span style="color:yellow">Pulp and Periapical Diseases</span>
# <span style="color:lime">Diagnostic Tests</span>
| | | | |
|---|---|---|---|
| | **Pulp sensibility tests** | | **Radiographs** |
| | ∘ Cold | | ∘ PA, Tube shifts, BW |
| | ∘ Heat | | **Transillumination** |
| | ∘ Electric | | ∘ Fibre optic light |
| | **Palpation** | | **Biting test** |
| | **Percussion** | | ∘ Tooth Slooth |
| | **Mobility** | | **Local anaesthesia** |
| | **Periodontal probing** | 9 | Test cavity |
64
$2^{nd}$ Year DMD - 2023 Page 32
### **Tests for Pain on Biting**
- Tooth Slooth
- FracFinder
> [!info] 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.
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Endodontic Examination**
* The history
* Exam findings, tests, radiographs, **etc**
* The **DIAGNOSIS**
* Which **TOOTH**, and
* The **CAUSE**
= Determine the **MANAGEMENT OPTIONS**
& help to assess the **PROGNOSIS**
65
**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)
66
$2^{nd}$ Year DMD - 2023
Page 33
# **Synthesizing the Diagnosis**
- 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)
Endodontic Diagnostic Procedures
**W/Prof. Paul V. Abbott AO**
Flow Chart for Diagnosing Common
Pulp and Periapical Diseases
67
<br>
<br>
Flow Chart for Diagnosing Common
Pulp and Periapical Diseases
68
2$^{\text{nd}}$ Year DMD - 2023 Page 34
```mermaid
flowchart TD
subgraph Pulpitis Side
P1["**1. Pulpitis or an Infected canal ?**"]
PS1["Thermal symptoms, **sharp pain**"]
P2A["**2 A. Reversible Pulpitis ?** or Irreversible Pulpitis ?"]
P2B["**2 B. Acute or Chronic ?**"]
P2C["**2 C. Apical Periodontitis also ?**"]
P2D["**2 D. If so, Acute or Chronic ?**"]
P1 --> PS1
P1 --> P2A
P2A --> P2B
P2B --> P2C
P2C --> P2D
end
subgraph Infected Canal Side
PS2["Ache, pain to **bite &/or chew**"]
RC3A["**3 A. Root Canal Condition**"]
RC3B["**3 B.** Necrotic & **Infected ?** or Pulpless & **Infected ?** or Previous Endodontic treatment & **Infected ?**"]
AP4A["**4 A. Periapical Condition**"]
AP4B["**4 B. Apical periodontitis ?** or Apical Abscess ? or Facial Cellulitis ?"]
AP4C["**4 C. Acute or Chronic ?** (except if Facial Cellulitis)"]
AP4D["**4 D. Primary or Secondary ?** (except if Facial Cellulitis)"]
P1 --> PS2
P1 --> RC3A
RC3A --> RC3B
RC3B --> AP4A
AP4A --> AP4B
AP4B --> AP4C
AP4C --> AP4D
P1 -- Long Pink Line --> P2D
P1 -- Long Pink Line --> AP4A
end
style P1 fill:#ffc107,stroke:#333
style PS1 fill:#ffc107,stroke:#333
style PS2 fill:#ffc107,stroke:#333
```
## **Initial Assessment: Pulpitis or Infected Canal?**
- **Pulpitis Side:** Characterized by thermal symptoms, **sharp pain**.
- **Infected Canal Side:** Characterized by an ache, pain to **bite &/or chew**.
**Endodontic Diagnostic Procedures** W/Prof. Paul V. Abbott AO
Page 35
2nd Year DMD **-** 2023
1. Pulpitis
Flow Chart for Diagnosing Common
Pulp and Periapical Diseases
2 A. Reversible Pulpitis ?
or Irreversible Pulpitis ?
2 B. Acute or Chronic ?
2 C. Apical Periodontitis also ?
2 D. If so, Acute or Chronic ?
Extreme temperature
changes, short duration
Extreme temperature
changes, short duration
Mild temperature change,
Lingering, Spontaneous,
short + sharp, aches
afterwards
Mild temperature change,
Lingering, Spontaneous,
short + sharp, aches
afterwards
Flow Chart for Diagnosing Common
Pulp and Periapical Diseases
2 A. Reversible Pulpitis ?
or Irreversible Pulpitis ?
2 B. Acute or Chronic ?
2 C. Apical Periodontitis also ?
2 D. If so, Acute or Chronic ?
More severe pain, short time
present (? days), most common
More severe pain, short time
present (? days), most common
Mild pain, present for long
time (? weeks, months)
Mild pain, present for long
time (? weeks, months)
1. Pulpitis
69
70
<center>
# Flow Chart for Diagnosing Common Pulp and Periapical Diseases (Image 1)
```mermaid
graph TD
A[1. Pulpitis] --> B[2 A. Reversible Pulpitis ? or Irreversible Pulpitis ?]
B --> C[2 B. Acute or Chronic ?]
C --> D[2 C. Apical Periodontitis also ?]
D --> E[2 D. If so, Acute or Chronic ?]
B --> F[Extreme temperature changes, short duration]
B --> G[Mild temperature change, Lingering, Spontaneous, short + sharp, aches afterwards]
```
</center>
<center>
# Flow Chart for Diagnosing Common Pulp and Periapical Diseases (Image 2)
```mermaid
graph TD
A[1. Pulpitis] --> B[2 A. Reversible Pulpitis ? or Irreversible Pulpitis ?]
B --> C[2 B. Acute or Chronic ?]
C --> D[2 C. Apical Periodontitis also ?]
D --> E[2 D. If so, Acute or Chronic ?]
B --> F[More severe pain, short time present (? days), most common]
C --> G[Mild pain, present for long time (? weeks, months)]
```
</center>
## **Diagnostic Pathway: Pulpitis**
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).
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
**Flow Chart for Diagnosing Common Pulp and Periapical Diseases**
```mermaid
graph TD
A[1. **Pulpitis**] --> B(2 A. **Reversible Pulpitis?** or **Irreversible Pulpitis?**);
B --> C(2 B. **Acute or Chronic?**);
B --> D(2 C. **Apical Periodontitis also?**);
D --> E(2 D. **If so, Acute or Chronic?**);
C --> F((Pain to biting &/or chewing, tenderness to percussion, radiographic changes));
D --> F;
E --> G((Based on time present (? days, weeks, months)));
```
71
**Flow Chart for Diagnosing Common Pulp and Periapical Diseases**
```mermaid
graph TD
A[1. **Infected canal**] --> B[3 A. **Root Canal Condition**];
A --> C[4 A. **Periapical Condition**];
B --> D[3 B. **Necrotic & Infected?** or **Pulpless & Infected?** or **Previous Endodontic treatment & Infected?**];
D --> E((No response to Pulp Tests, recent problem, no periapical radiographic changes));
D --> F(((No response to Pulp Tests, problem present for longer period of time, periapical radiolucency present)));
D --> G((History or radiographic signs of previous treatment; periapical radiolucency present));
D --> H[4 B. **Apical periodontitis?** or **Apical Abscess?** or **Facial Cellulitis?**];
C --> H;
H --> I[4 C. **Acute or Chronic?** (except if Facial Cellulitis)];
I --> J[4 D. **Primary or Secondary?** (except if Facial Cellulitis)];
```
72
2nd Year DMD - 2023 Page 36
## **Diagnostic Pathway: Infected Canal**
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.
> [!example] 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.==
3. **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.
**Endodontic Diagnostic Procedures** W/Prof. Paul V. Abbott AO
$2^{nd}$ Year DMD - 2023 Page 37
73
```mermaid
flowchart TD
subgraph Flow Chart for Diagnosing Common Pulp and Periapical Diseases
A[**1. Infected canal**] --> B[**3 A. Root Canal Condition**];
A --> E[**4 A. Periapical Condition**];
B --> C[**3 B. Necrotic & Infected ? or Pulpless & Infected ? or Previous Endodontic treatment & Infected ?**];
E --> F[**4 B. Apical periodontitis ? or Apical Abscess ? or Facial Cellulitis ?**];
F --> G[Pain to bite &/or chew, tender to percussion];
F --> H[Localised collection of pus, swelling, fever, etc];
F --> I[Spreading infection through face, pus, swelling, fever, etc];
E --> J[**4 C. Acute or Chronic ? (except if Facial Cellulitis)**];
E --> K[**4 D. Primary or Secondary ? (except if Facial Cellulitis)**];
G --> J;
H --> J;
I --> K;
end
```
74
```mermaid
flowchart TD
subgraph Flow Chart for Diagnosing Common Pulp and Periapical Diseases
A[**1. Infected canal**] --> B[**3 A. Root Canal Condition**];
A --> E[**4 A. Periapical Condition**];
B --> C[**3 B. Necrotic & Infected ? or Pulpless & Infected ? or Previous Endodontic treatment & Infected ?**];
E --> F[**4 B. Apical periodontitis ? or Apical Abscess ? or Facial Cellulitis ?**];
F --> G[Pain, short time present (? days)];
F --> H[Nil or mild pain, present for long time (? weeks, months), draining sinus if apical abscess];
E --> J[**4 C. Acute or Chronic ? (except if Facial Cellulitis)**];
E --> K[**4 D. Primary or Secondary ? (except if Facial Cellulitis)**];
G --> J;
H --> J;
end
```
$2^{nd}$ Year DMD - 2023 Page 37
4. **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**.
5. **Assess Origin (Primary or Secondary?):**
- *Except if Facial Cellulitis*
Endodontic Diagnostic Procedures W/Prof. Paul V. Abbott AO
Flow Chart for Diagnosing Common
Pulp and Periapical Diseases
75
```mermaid
graph TD
A[1. **Infected canal**] --> B(3 A. Root Canal Condition);
B --> C(3 B. Necrotic & Infected ? or Pulpless & Infected ? or Previous Endodontic treatment & Infected ?);
A --> D(4 A. Periapical Condition);
C -- No radiolucency or slight thickening of PDL --> E(4 B. Apical periodontitis ? or Apical Abscess ? or Facial Cellulitis ?);
C -- Periapical radiolucency present --> F(4 B. Apical periodontitis ? or Apical Abscess ? or Facial Cellulitis ?);
D --> E;
D --> F;
E --> G(4 C. Acute or Chronic ? (except if Facial Cellulitis));
F --> G;
G --> H(4 D. Primary or Secondary ? (except if Facial Cellulitis));
style A fill:#000,stroke:#f00,color:#fff
style B fill:#ffd700,stroke:#000,color:#000
style D fill:#ffd700,stroke:#000,color:#000
style C fill:#ffd700,stroke:#000,color:#000
style E fill:#fffacd,stroke:#000,color:#000
style F fill:#ffd700,stroke:#000,color:#000
style G fill:#ffd700,stroke:#000,color:#000
style H fill:#ffd700,stroke:#000,color:#000
```
Flow Chart for Diagnosing Common
Pulp and Periapical Diseases
76
```mermaid
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
```
2<sup>nd</sup> Year DMD - 2023
Page 38
### **Radiographic Correlation for Infected Canals**
- **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**
```mermaid
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
`
[[L15 Endodontic Diagnostic Procedures.pdf#page=1|L15 Endodontic Diagnostic Procedures, p.1]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=2|L15 Endodontic Diagnostic Procedures, p.2]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=3|L15 Endodontic Diagnostic Procedures, p.3]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=4|L15 Endodontic Diagnostic Procedures, p.4]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=5|L15 Endodontic Diagnostic Procedures, p.5]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=6|L15 Endodontic Diagnostic Procedures, p.6]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=7|L15 Endodontic Diagnostic Procedures, p.7]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=8|L15 Endodontic Diagnostic Procedures, p.8]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=9|L15 Endodontic Diagnostic Procedures, p.9]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=10|L15 Endodontic Diagnostic Procedures, p.10]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=11|L15 Endodontic Diagnostic Procedures, p.11]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=12|L15 Endodontic Diagnostic Procedures, p.12]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=13|L15 Endodontic Diagnostic Procedures, p.13]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=14|L15 Endodontic Diagnostic Procedures, p.14]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=23|L15 Endodontic Diagnostic Procedures, p.23]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=24|L15 Endodontic Diagnostic Procedures, p.24]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=25|L15 Endodontic Diagnostic Procedures, p.25]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=26|L15 Endodontic Diagnostic Procedures, p.26]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=27|L15 Endodontic Diagnostic Procedures, p.27]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=28|L15 Endodontic Diagnostic Procedures, p.28]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=29|L15 Endodontic Diagnostic Procedures, p.29]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=30|L15 Endodontic Diagnostic Procedures, p.30]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=31|L15 Endodontic Diagnostic Procedures, p.31]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=32|L15 Endodontic Diagnostic Procedures, p.32]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=33|L15 Endodontic Diagnostic Procedures, p.33]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=34|L15 Endodontic Diagnostic Procedures, p.34]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=35|L15 Endodontic Diagnostic Procedures, p.35]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=36|L15 Endodontic Diagnostic Procedures, p.36]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=37|L15 Endodontic Diagnostic Procedures, p.37]]
[[L15 Endodontic Diagnostic Procedures.pdf#page=38|L15 Endodontic Diagnostic Procedures, p.38]]