Intro and Diagnosis

Lecture on 8/6/2025

every diagnosis needs to consist of…

2 parts, a pupal and periapical diagnosis

what tools/tests are commonly used for pulpal diagnosis?

cold test, EPT, heat, radiographs (to determine previous treatment)

what tools/tests are commonly used for apical diagnosis?

percussion, palpation, radiographs

what are other tests that can be done to make a pulpal or apical diagnosis?

probing, mobility, transillumination, bite stick, cavity test, cone beam CT

what are all pulpal/apical tests (BESIDES radiographs) considered?

sensory tests

what can the transillumination test help you do?

idenitify cracks

what can the bite stick test help you do?

identify cusp fracture

what tests should be done on any patients that come in with tooth pain?

cold test, radiographs, percussion, palpation, probing, and mobility

what kind of tests are pulpal and apical tests, and what does that mean in terms of testing?

they are comparative tests, so a baseline needs to be established first (test normal teeth before suspected hurt tooth)

what are some things to consider when doing an endodontic consult?

calcification, recent trauma, more than one tooth hurting, as these can all alter results

vitality tests

assess the response of the pulp to different stimuli, an abnormal response may indicate degenerative changes in the pulp

cold test- no response

pulp necrosis

cold test- moderate transient response

normal pulp

cold test- quick painful response

often reversible pulpitis

cold test- lingering painful response

often irreversible pulpitis

t/f none of these vitality tests can evoke a painful response so don’t worry about hurting a patient

false- they can provoke a painful reaction to they should be carefully performed and explained to the patient

what do you need to perform a cold test?

cold refrigerant, cotton forceps, and a small pellet of cotton, NOT wooden q-tips

t/f before performing a cold test, you should dry the tooth

true

what kinds of teeth may give a false negative or false positive on cold tests?

multi-rooted teeth where not all roots are affected, teeth with calcified canals, and teeth with recent trauma

what are the steps for using an electronic pulp tester?

dry tooth, apply toothpaste or topical to electrode tip, place the tester near the incisal 1/3 of tooth, complete the circut

what is the purpose of the EPT?

stimulate the sensory nerve fibers of the pulp to produce a response, used when we don’t trust the results of a cold test

EPT- no response

frequently pulp necrosis

EPT- positive response

intact vital pulp or partially necrotic pulp

t/f EPT can be used to differentiate between a tooth that is fine and a tooth that has irreversible pulpitis

false- it does not provide any information about the condition of the vascularity of the pulp

t/f the numbers on the EPT are valuable for determining how necrotic the pulp is

false- numbers cannot be used to make any determinations about pulp vitality

how is a percussion test performed?

tapping on the incisal or occlusal surfaces of the teeth usually with a blunt instrument like the back end of a mirror handle

what does a percussion test tell you, and what does it NOT tell you?

indicates the presence of periradicular inflammation (something is bothering the PDL)

does not disclose the condition of the pulp

what are common/possible causes for a ‘positive’ result on a percussion test?

pulpal issues, periodontal issues, recent trauma, recent high filling, ortho…

percussion- abnormal positive response

inflammation of PDL that may be either pulpal or periodontal origin

t/f percussion does not need to be done on control teeth at first

false- the sensitivity of proprioceptive fibers in the inflammed PDL will help identify the location of pain, but it needs to be compared to a control first

palpation

applying firm digital pressure to the mucosa covering the roots and apices, with the index finger the mucosa is pressed against the underlying cortical bone

what does palpation do?

aids in detecting the presence of periradicular abnormalities or areas that produce a painful response to digital pressure

palpation- positive response

may indicate active periradicular inflammation process, but it does not indicate if it is of endodontic or periodontal origin

how is mobility testing performed?

using 2 mirror hanfles on each side of the crown, pressure is applied in a facial-lingual direction as well as in a vertical direction and the tooth is then scored

tooth mobility is directly proportional to the…

integrity of the attachment apparatus or to the extent of inflammation in the PDL

t/f a periradicular abscess of pulpal origin may cause mobility similar to fractured roots or recent trauma

true- must be verified with other tests

what can radiographic examination aid in detection of?

carious lesions, extensive or defective restorations, pulp caps, pulpotomies, previous root canal treatment and possible mishaps, stages of root formation, canal obliteration, root resorption, root fractures, periradicular radiolucencies, thickened periodontal ligament, alveolar bone loss

what can bitewing radiographs show?

details about the pulp- existing fillings, bases/liners, previously initiate treatment, depth, calcification, pulp stones

what can PA radiographs show?

canal size and location, calfications, apical pathology, foramen, resorption, incomplete root formation, previously separated files

periapical cemento-osseous dysplasia

vital teeth, but radiographs show multiple radiolucencies at the apicies, should not be misdiagnosed as inflammatory apical lesions

how does transillumination look different in a cracked versus non-cracked tooth?

cracked- light is not transmitted to the entire tooth

not cracked- light is transmitted from one side of the tooth to the other

what is the classic symptom of a cuspal fracture when using a bite stick?

electric shock feeling

what options do you have for testing on a tooth with a full coverage crown?

using a cotton roll and endo ice and holding on the crown for longer

EPT by retracting the gingival tissue and applying EPT to original tooth

heat testing

duplicate heat pain by using warm gutta percha

why is selective anesthesia used?

to rule out an arch (patients can mistake/have referred pain from one arch to another)

cavity testing

drill through a crown without anesthesia, get into the dentin and see if patient has sensitivity

blood flow test

determine vitality of pulp by measuring its blood flow riather than response by sensory nerves

systems include dual wavelength spectrophotometry, pulse oximetry, and laser doppler have been developed to measure oxyhemoglobin, low concentration of blood, or pulsation of the pulp

is blood flow testing a practical test to use?

no- systems need to be highly tailored to a single tooth

what are the potential pulpal diagnoses?

normal pulp, reversible pulpitis, irreversible pulpitis (symptomatic or asymptomatic), pulp necrosis, previously treated, or previously initiated therapy

what are the potental apical (periapical) diagnoses?

normal apical tissues, symptomatic apical periodontitis, asymptomatic apical periodontitis, acute apical abscess, chronical apical abscess

normal pulp diagnosis

no spontaneous symptoms, will respond normal to pulp test (mild, transient sensation that will disappear in seconds)

may or may not have pulpal calcification, usually no evidence of resorption, caries, or mechanical pulp exposure

reversible pulpitis diagnosis

pulp is irritated, responds to vitality testing (may seem more uncomfortable) but reverses quickly after stimulation, conservative removal/correction of the irritant should resolve the symptoms

possibly caused by caries, exposed dentin, recent dental treatment, or defective restoration

confusion can occur with exposed dentin (recession)

what type of pain do C fibers cause?

dull, throbbing pain

what type of pain do A delta fibers cause?

sharp, quickly reversible pain

which way does dentin tubule fluid move in pain caused by dehydration, cold, or hyper-osmotic solutions?

outward (away from sensory nerves)

which way does dentin tubule fluid move in pain caused by heat?

inward (towards sensory nerves)

symptomatic irreversible pulpitis diagnosis

intermittent or spontanteous pain, dramatic exposure to temperature changes results in heightened and prolonged pain even after stimulus has been removed, incapable of healing

pain can be sharp or dull, localized or diffused, or referred

usually minilar or no changes on radiograph but advanced cases may displat thickening of PDL

possibly caused by deep restorations, caries, pulp exposure, direct or indirect insult of pulp (recent or past)

if left untreated, pulp will become necrotic

asymptomatic irreversible pulpitis diagnosis

no symptoms but if left untreated it may become symptomatic or necrotic, incapable of healing

sometimes deep caries will not produce any symptoms even though caries may extend well into the pulp

needs to be treated or could become painful/problematic

pulp necrosis diagnosis

blood supply nonexistant, nerves are nonfunction, tooth may be asymptomatic until extension of disease process into the periradicular tissues (percussion pain or spontaneous pain)

no response to EPT or cold tests, may respond to heat

pulp necrosis may be partial or complete

radiographic changes may occur (thickening or PDL or periapical lesion)

tooth may become hypersensitive to heat and is relieved by applications of cold

previously treated diagnosis

root canal system has been filled with some type of FINAL obturating material, may or may not present with signs or symptoms but requires additional treatment

is calcium hydroxide a final obturating material?

no

previously initiated therapy diagnosis

partial endodontic therapy (pulpotomy or pulpectomy), often done in emergency situations

can be cases of vital pulp therapy, traumatic tooth injuries, apexification, or apexogenesis

normal apical tissues diagnosis

asymptomatic, tooth responds normal to percussion and palpation, intact lamina dura and PDL spaces around all root apices

symptomatic apical periodontitis diagnosis

acutely painful to biting or percussion, may or may not respond to vitality tests (pulpal diagnosis is different!!), generally at least widened PDL and may or may no have a radiolucent lesion at root(s)

asymptomatic apical periodontitis diagnosis

generally no clinical symptoms, usually no response to vitality tests, usually an apical radiolucency, generally no sensitive to biting but may ‘feel different’ on percussion test

acute apical abscess diagnosis

acutely painful to biting, percussion, palpation, no response to vitality tests, may be mobile, ranges from widened PDL to apical radiolucency, swelling, may be febrile, tender lymph nodes

what differentiates acute and chronic apical abscess diagnoses?

acute must have swelling, chronic must have intermittent drainage through a sinus tract

chronic apical abscess diagnosis

generally no clinical symptoms, no response to vitality tests, an apical radiolucency, generally not sensitive to biting but may ‘feel different’ on percussion test, exhibits intermittent drainage through a sinus tract

what does drainage through a sinus tract usually present as?

a ‘pimple’ on the gingival that comes and goes

how can you trace a sinus tract and why should you do it?

insert gutta percha into the tract (into the pimple on gingiva), usually without any anesthesia, and take a radiograph

will help you determine source of infection

calcific metamorphisis

calcification of the pulp chamber and root canals, 5-15% will need root canal treatment

condensing osteitis

diffuse radiopaque lesions representing a localized bony reaction to a low-grade inflammatory stimulus, usually seen at the apex of the tooth, often with pulpitis or pulp necrosis, follow appropriate treatment there is usually partial or total resolution of the lesion over time

causes more bone production rather than bone destruction in the area

condition occurs over a broad age range with a predilection for young patients and the premolar/molar region of the mandible

fast break

in radiographs, an abrupt disappearance of the large canal, usually signifies a canal bifurcation