Handbook of Clinical Endodontics Pramod Bansi Mathur, Sanjay Bansi Mathur
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History and Clinical Diagnostic Methods1

Successful treatment in Endodontics is based upon correct diagnosis of dental pulp disease, which depends upon, what one sees, feels, is suggested (history of the patient) observes and then it's synthesis with the previous knowledge one possesses.
The term diagnosis may be clinical or laboratory, various tests that are available for the diagnosis of pathology in the pulp are:
  1. History
  2. Visual examination
  3. Percussion
  4. Palpation
  5. Mobility test
  6. X-ray test
  7. Electric pulp testing
  8. Transillumination test
  9. Anesthetic test
  10. Test cavity
  11. Thermal test
Individually these tests may seldom be helpful in diagnosis of any pathology, but in combination they are indispensable in reaching a diagnosis.2
 
GENERAL HISTORY
Cardiovascular system: Heart disease, rheumatic fever, syncope, angina pectoris, hypertension, cardiac surgery, chorea, dyspnoea, bleeding disorders, anticoagulants, anaemia etc.
Respiratory system: Asthma, cough, bronchitis, TB, smokers, or any other chest disease.
Urinary tract infection: Menstrual problems, pregnancy, last delivery, etc. Renal, urinary tract or sexually transmitted diseases.
Gestrointestinal system: Coeliac disease, Crohn's disease, hepatitis, jaundice.
Central nervous system: CVA, multiple sclerosis, other neurological diseases, psychiatric problems, sight or hearing problems, alcohol or drugs abuses, etc.
Skeletal/muscular system: Bone muscle or joint diseases/pain, etc.
Endocrine and Allergies: Diabetes, thyroid, other endocrine disorders Allergies; e.g. Penicillin, aspirin, local anesthetic solution, or any other drugs, etc.
Drugs: Recent or current drugs/medical treatment, steroids, aspirin, etc (aspirine prolongs BT, CT).
Skin disease: Skin diseases, use of cream or ointments, etc.
Serious illness: Previous operations, GA or any previous serious illnesses.
Other conditions: Other conditions including congenital abnormalities family RHM Race, Zonal, Travelling abroad and revelent questions.3
 
DENTAL HISTORY
A general history and observations of the dental conditions help to establish a correct diagnosis.
 
Note the Following
  1. General hygienic condition of the mouth including periodontal status.
  2. Blood pressure, blood sugar estimation, differential count, ESR, BT CT and urine analysis report.
  3. Number of pulpless teeth present/rampant caries.
  4. If pain is present its location, duration, character, radiation to, etc. should be explored.
  5. Pain as described by patient; whether sharp, dull, throbbing or boring type, duration, whether continuous or intermittent, frequent, or infrequent, it's radiation to etc. assist a lot in reaching a diagnosis.
  6. If pulp is exposed, it's color, consistency, odour, should be observed, whether pulp is vital, non-vital, these findings are important landmarks.
 
DIAGNOSTIC TESTS
Procedure
Advantage
Disadvantage
Remarks
1. Percussion (Tapping & pressure)
Simple, may reveal periostatic teeth (Tenderness in tooth on percussion in periodontitis may have vital pulp)
Crude
Teeth may be periostatic due to abscess formation (Maxillary teeth may be periostatic if there is sinusitis)
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2. Application of hot or cold stimuli to teeth (thermal test)
Simple
Crude, heat or cold may be transferred to adjacent teeth.
Cold stimuli may be useful to locate pulpitic teeth or exposed dentine.
Methods to apply heat or cold to the tooth for thermal testing: -
Cold Test:
1. Ice cubes/sticks.
2. Carbon-dioxide capsules/dry ice.
3. Ethyl chloride spray.
4. Freon-12 (In pen used by ophthalmologists for cataract operation.)
5. Ice balls (Small plastic capsules may be filled with water and freezed)
Heat Test:
1. Bar/back of handle of mouth mirror may be heated warmed on flame and applied on tooth.
2. Heated gutta-percha stick (Stick end may be warmed on flame and applied to tooth)
3. Hot water (Small plastic capsules filled with water and heated in a tub of water/or in sterilizer)
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Fig. 1.1: Thermal test using ice in wet gauze
3. Electric pulp test
Simple
Unpleasant, may May be useful to give false positive locate pulpitic tooth. or negatives. Requires special apparatus.
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Fig. 1.2: Electric pulp tester
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4. Radiography
Simple, can reveal caries, apical pathologies fractures, and much pathology in jaws.
Pulp exposure may be missed as view is only two-dimensional, caries does not show well on extra-oral films.
Simple periapical films are valuable; Bitewing films do not show the periapical bone.
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Fig. 1.3: Apical pathology
5. Visual examination.
Simple, can reveal swellings, fistula openings, ulcers and much pathology in mouth.
Crude, may reveal dead pulp by chance, by change of color of tooth/or hue etc.
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Fig. 1.4: Intra-oral Fistula
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Fig. 1.5: Ulcer on tongue
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6. Palpation
Simple, can give idea of glandular involvement
Crude, may give flatulence on bimanual palpation to consider incision and drainage timings.
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Figs 1.6 and 1.7: Bimanual palpation and submandibular palpation
7. Mobility
Simple, give idea of prognosis etc.
Crude, it should be done using two tongue blades, as pulp of operator's finger may mislead and give a false idea of mobility. First stage mobility is noticeable movement of the tooth. Second stage mobility is noticeable movement of tooth in the range of 1 mm. Third stage mobility is more than 1 mm. Endodontic treatment should be limited upto second degree of mobility only.
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Fig. 1.8: Testing mobility of a tooth using two wodden tongue blades
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Fig. 1.9: Testing mobility of the tooth between two mirror handles, because operators finger pulps may cive a false reading
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8. Transillumination test. A strong beam of light from behind, seen through the tooth in a dark foreground
Simple, reveals non-vital discolored pulp tissue, apical cyst, etc.
The size of the dark shadow may reveal the size of the pathology/color etc.
zoom view
Fig. 1.10: Transillumination test
9. Test cavity/filling test.
Simple, reveals chronic open pulpitis, sensitivity, etc.
10. Anesthetic test
Simple, reveals or can help in location of debatious tooth.
Limited, only possible if pain is present at the time of examination.
zoom view
Fig. 1.11: Diagram showing infection (caused by bacteria) in the canal and different zones of inflammation in the soft tissues around apical foramen from where the infection is causing tissue irritation.
  1. Zone of infection (Presence of polymorphs)
  2. Zone of contamination (Presence of round cell infection and prevalence of lymphocytes)
  3. Zone of irritation (Presence of macrophages and oesteoclasts)
  4. Zone of stimulation (Presence of fibroblasts and oestoclasts) (In this zone presence of cell rests of malassez, if present, may get stimulated to result into a cyst formation).
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How to Investigate a Case of Trauma/Injury
  1. History of the patient.
    1. Medical
    2. Dental; any injury in the past.
    3. Injury.
      • How it was sustained when, where, and by what?
  2. Neurological examination
    1. Cranial nerves
    2. History of
      • Headache
      • Nausea/vomiting
      • Lethargyness
      • Unconsciousness
      • Amnesia
      • Orientation regarding persons, place, time, etc.
  3. Head examination.
    1. Skin
      • Abrasions
      • Lacerations
      • Contusions
      • Ecchemosis
      • Oedema
    2. Bones
      • Crepitus
      • Mobility
      • Tenderness
      • Asymmetry
    3. Ears
    4. Nose
    5. Eyes.
  4. TM Joint assessment.
    1. Joint pain
    2. Muscular Pain
      1. Intra-oral opening.
      2. Any deviation on opening.
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      3. Locking during opening/closing.
      4. Difficulty in chewing etc.
  5. Oral examination.
    1. Oral mucosa, Gingiva and Tongue.
      1. Any abrasions.
      2. Contusions
      3. Lacerations etc.
    2. Periodontal condition.
    3. Occlusion.
      1. Angle's classification
      2. Open-bite
      3. Over-jet.
        • Disruption; ask the patient if his/her teeth meet as they used to do before accident.
    4. Condition of teeth.
      Color changes if any.
      Pain
      • on bite
      • with cold
      • on percussion
      • at rest
      Mobility
      Response of electric pulp testing
      Any fracture (crown, root, etc.)
      Any luxation present (lateral, avulsion, sub-luxation)
      X-rays.
      Pathological reports
      Follow up reports etc.
      (As per WHO instruction list)
 
Classification of the Dental Injuries
 
Enamel Fractures
Involves enamel only and include enamel chipping and complete fracture or enamel cracks.10
 
Crown Fracture Without Pulp Involvement
An uncomplicated fracture of the tooth involving enamel, and dentine, but no pulp exposure.
 
Crown Fracture with Pulp Involvement
A complicated fracture involving enamel, dentine and exposure of the tooth pulp
 
Root Fracture
Fracture of the root of the tooth involving cementum, dentine, and pulp, also referred as “horizontal root fracture.”
 
Crown Root Fracture
Tooth fracture that involves enamel, dentine, and root cementum and may or may not include the pulp.
 
Luxation
There are many sub-categories of this type of injury.
 
Concussion
The tooth is sensitive to percussion but has not been displaced and is not abnormally mobile.
Sub-luxation: The tooth has increased mobility but has not been displaced
Lateral-luxation: The tooth has been displaced and may be very firm.
Extrusive-luxation: The tooth is very mobile, because of partial displacement out of socket.
Intrusive-luxation: The tooth has been forced apically and is firmly embedded in the bone.
Avulsion: Complete displacement of a tooth from its socket.
Fracture of the alveolar process: Mandible, or Maxilla Fracture or comminution of the alveolar socket or the alveolar process; if the fracture involves a tooth socket, the blood supply to the pulp of the tooth may be compromised (Based on WHO system).