6.ENDODONTIC DIAGNOSIS AND RECENT MODALITIES.pptx

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1. DIAGNOSIS IN ENDODONTICS AND RECENT IMAGING MODALITIES

2. The art of identifying a disease from its signs and symptoms. The purpose of the diagnosis is to determine what problem the patient is having and why the patient is having that problem. What is diagnosis?

3. The process of making a diagnosis can be divided into five stages: The patient tells the clinician why the patient is seeking advice. The clinician questions the patient about the symptoms and history that led to the visit. The clinician performs objective clinical tests. The clinician correlates the objective findings with the subjective details and creates a tentative differential diagnosis. The clinician formulates a definitive diagnosis.

4. Chief complaint Medical history Dental history Clinical inspection Diagnostic tests Radiographic Interpretation Data Evaluation Diagnosis

5. Subjective symptoms Generally patients seeks the dentist for his chief complaint. It may relate to pain, swelling, lack of function or esthetics, which the patient has brought him to the dentist. Pain : Common complaint which leads to the dental treatment One should ask the patient about the kind of pain, its location, its duration, what causes it, what alleviates it

6. Brannstrom’s hydrodynamic theory: Pulp Nociception Mechanism Proposed that pulp pain is a result of nociceptors activated by fluid movement with possible other irritants through the patent dentine tubules PULPITIS resulting from rapidly progressing caries as an example, seems to be more likelihood of having pain because there is less time for the dental pulp to react and protect itself by occluding the dentinal tubules

7. Sharp, piercing and lancenating . Faster rate of transmission Responds to pain, temperature, touch Diameter is 1-5 µm Conduction velocity 6-30 m/sec. Has mylein sheath Located in the periphery of pulp, penetrating the inner part of dentin. Dull, boring, gnawing and excruciating. Slower rate of transmission Responds to pain Diameter 0.4-1.o µm Conduction velocity 0.5-2 m/sec Does not so Located in deeper part of pulp proper. A delta fibers C fibers

8. Lymph node examination Extra-oral Examination

9. Extra oral sewlling of odontogenic origin typically is the result of endodontic etiology. Swelling Abscess Cellulitis

10. Space Infection

11. Intra-Oral Examination Soft Tissue Examination There should be a routine examination of the intra oral soft tissues. The gingiva and mucosa should be made dry or wipe with gauze. Any raised lesions or ulcerations should be documented and when necessary, evaluated with biopsy or referral

12. Color : Normal teeth show life like translucency and sparkle that is missing in pulpless teeth which appear more or less opaque. Contour : examination of contours of affected teeth, such as fractured teeth, wear facets, improperly contoured restorations or altered crown contours - as these factors can have marked effect on the respective pulps. Consistency : change in consistency is related to presence of caries, external and internal resorption . Hard Tissue

13. In diagnosis think of the easy first.   Martin H. Fischer

14. Tooth is struck with a quick, moderate blow initially with low intensity by the finger, then with increasing intensity by using handle of an instruments. A positive response to percussion indicates not only the presence of inflammation of periodontal ligament but also the degree of inflammation. Percussion

15. Simple test done with finger tip using light pressure to examine tissue consistency and pain response. Presence, intensity and location of pain. Presence and location of adenopathy Presence of bone crepitus . Whether tissue is fluctuant and enlarged When infection confined to pulp palpation is not diagnostic. Palpation

16. Rationale of mobility test is to evaluate the integrity of the attachment apparatus surrounding the tooth. Test consists of moving the involved tooth facio-lingually using handles of two instruments or using two index fingers. Test for depressibility is performed by applying pressure in an apical direction on the occlusal / incisal aspect of tooth and observing vertical movement if any. Mobility and Depressability

17. Periodontal examination Consists use of a blunt calibrated probe to explore the integrity of gingival sulcus around each tooth. To distinguish disease of periodontal origin from pulp origin, thermal and EPT along with PDL probing are essential.

18. Furcation Defects Class I: The furcation can be probed but not to a significant depth Class II: The furcation can be entered into but cannot be probed completely through to opposite side. Class III: The furcation can be probed completely through the opposite side.

19. Pulp Sensibility tests Pulp Vitality tests Assessment of the Pulp’s Sensory Response: Sensibility is defined as the ability to respond to a stimulus Assessment of the Pulp’s Blood Supply : Pulp tissue may have an adequate vascular supply, but is not necessarily innervated . Thermal test Heat test cold test Electric Pulp Tester Laser Doppler Flowmetry Pulse Oximetry Surface temperature measurement

20. Others Radiographs Test cavity Anaesthetic test Transillumination Bite test

21. Heat test Gutta percha stick Hot burnisher Hot water Hot air Hot compound Polishing cups

22. Cold test Cold air Ice sticks and CO 2 snow(-78 ºc) Dichloro - difluoro -methane(-26ºc) Ethyl chloride spray (-50ºc)

23. No response Mild to moderate degree of pain that subsides within 1-2 sec after stimulus has been removed Strong, momentary painful response that subsides within 1-2 secs after stimulus is removed Moderate to strong painful response that lingers for several seconds or longer after stimulus has been removed Responses to thermal tests Non-vital pulp is indicated. Normal Reversible pulpitis Irreversible pulpitis

24. Retract the patient’s cheek with free hand, this completes the circuit Turn on the rheostat slowly introduce minimal current into the tooth and increase the current slowly. Ask the patient to indicate tingling or warmth sensation, and note the recordings. Repeat the foregoing for each tooth to be tested. Describe the test in a simple way so that it reduces the patient anxiety. Isolate the area of the teeth by suction and cotton rolls. Check the EPT. Apply electrolyte on the tooth electrode and the dried enamel (should not contact the restoration or gingival tissue ). EPT is designed to stimulate a response of sensory fibres within the pulp by electric excitation. Electric pulp tester Procedure

25. Disadvantage : Cannot be used on patients having cardiac pace maker. Does not suggest the health or integrity of the pulp, simply indicates the presence of vital sensory fibres with in the pulp. Does not provide any information about vascular supply of pulp, which is the true determinant of pulp vitality.

26. Recently traumatized teeth Incomplete root formation Sedative medication taken by the patient Unusual pain thresold by the patient. Teeth with extensive restoration False Positive False Negative Response means pulp is necrotic, patient feels sensation in tooth. Response means that pulp is vital, but patient does not respond. Gangrenous pulp in root canal Multi-rooted teeth Electrode may contact the metal restoration

27. Bisecting Angle Technique Paralleling technique Radiographic Examination Image distortion seen Distortion is greater in apical zone Anatomical land marks altered Crown-root ratio not preserved Poor image standardization and reproducibility Slight image distortion Distortion equal throughout the image Correct anatomical relationships Crown-root ratio preserved High image standardization and reproducibility

28. Presence of caries that may involve or threat to involve the pulp. May show the number, curve, length and width of root canals. Presence of calcified materials in the pulp chamber or root canals. Radiographs Contain Information Resorption of dentin originating with in the root canal or from the root surface. Thickening of PDL Nature and extent of periapical and alveolar bone destruction.

29. Developed in France by Dr. Francis Mouyen in 1984. The system provides an instantaneous image on a video monitor while reducing radiation exposure by 80%. Three components: Radio component Visio component Graphy component Radiovisiography : RVG

30. 1. Radio component: It consists of a hypersensitive intra-oral sensor and a conventional X-ray unit. The small sensor consist a fluoroscopic sensor screen, a set of optic fibres , and a miniature charged coupling device; that translates the image produced into an electronic signal that is transmitted to display – processing unit. 2. Visio component: It consists of a video monitor and display – processing unit. As the image passes to the processing unit, it is digitized, memorized by the computer and immediately displayed on the monitor. This image is magnified four times.

31. 3. Graphy component: A high resolution printer that instantly provides a hard copy of the screen image, using the same signal. Advantages: Eliminates the use of X-ray film. Significant reduction in exposure time (100th of sec). Instantaneous image display. It can display multiple images. As the image is digitalized further manipulation of image is possible.

32. Helps in the detection of radiographic changes by decreasing the amount of distracting background information . By allowing the eye to focus on the actual change that has occurred between the two images Digital Subtraction Radiography

33. A radiographic image is generated before a particular treatment is performed. At some time after the treatment, another image is generated.  The two images are digitized and compared on a pixel-by-pixel basis.  The resultant image shows only the changes that have occurred and “subtracts” those components of the image that are unchanged. Mechanism: In diagnosis of periodontal progression In diagnosis of healing after root canal therapy In diagnosis of the progression of periradicular lesions.

34. Invented by Chester.F Carlson in 1937. Xeroradiography

35. Anaesthetic test If source of pain is not determined whether in maxillary or mandibular give inferior alveolar block. Using either infiltration or the intraligamentry injection inject the most posterior tooth in the area suspected of being the cause of pain. If pain persists, anesthesize the next tooth mesial to it and continue to do so until the pain disappears.

36. Test Cavity Direct dentin stimulation. The test cavity involves slow removal of tooth structure to determine pulp vitality. The cavity is prepared with a round bur at slow speed without a coolant- unanesthetized tooth. This test is carried out only when other means have failed therefore disadvantage of this test is iatrogenic damage. Pain or sensation felt by patient indicates vital pulp and test is performed on other teeth until the involved tooth is found.

37. The test requires shining a light from lingual / palatal surface. Transmission of powerful fiber optic light through teeth helps to detect a fracture mainly the vertical. During this test, operating light is switched off and fiberoptic light is moved closed to neck of the tooth. Light does not pass through fracture, thus the part of tooth beyond fracture remains dark. In teeth with necrotic pulps the shadow of the pulp canal space appears darker than the rest of the tooth because of the break down of the blood cells. In vital pulps no differentiation is noted. Transillumination

38. The tooth may be sensitive to biting when the pulpal pathosis has extended into the periodontal ligament space, creating a peri-radicular periodontitis or secondary to a crack in the tooth. If peri-radicular periodontitis is present the tooth will respond with pain to percussion and biting test,regardless where the pressure is applied to the coronal part of the tooth. A cracked tooth and fractured cusp will elicit pain only when the percussion or bite test is applied on a certain direction to one cusp or section of the teeth. Bite Test

39. Crown surface temperature/heat registration Laser Doppler flowmetry Pulse oximetry Computerised tomography Plethysmography CBCT MRI- Magnetic resonance imaging Ultrasound Transmitted Laser Light Recent Advances

40. Crown Surface Temperature/Heat Registration Show that when teeth have been cooled, non-vital teeth were slower to rewarm than vital teeth

41. LDF is another non-invasive method for assessing blood flow in microvascular systems. It use in teeth was first described by Gazelius and co-workers in 1986. Since then, the technique has been widely used to monitor dynamic changes in pulpal blood flow in response to pressure changes and following administration of local anaesthesia Laser Doppler Flowmetry

42. Motion artefact due to uncontrolled movement of the probe when placed against the tooth. Blood pigments within a discolored tooth crown can also interfere with laser light transmission

43. It was invented by Aoyagi in the early 1970, for recording blood oxygen saturation levels during the administration of intravenous anaesthesia . Pulse Oximetry The pulse oximeter sensor consists of two light-emitting diodes, one to transmit red light (640 nm) and the other to transmit infrared light (940 nm), and a photodetector on the opposite side of the vascular bed. Oxygenated haemoglobin and deoxygenated haemoglobin absorb different amounts of red/infrared light. The pulsatile change in the blood volume causes periodic changes in the amount of red/ infrared light absorbed by the vascular bed before reaching the photodetector . The relationship between the pulsatile change in the absorption of red light and the pulsatile change in the absorption of infrared light is analysed by the pulse oximeter to determine the saturation of arterial blood.

44. Normal Teeth Necrotic teeth

45. Evanes et al 1999 Comparison of LDF, Ethyl Chloride, and EPT.

46. It is a method for assessing the changes in volume and has been applied to the investigation of arterial disease. It can be performed using air filled cuffs or mercury in rubber strain gauges. As the pressure pulse passes through the limb segment, a wave form is recorded which relates closely to that obtained by intra-arterial cannulation The same principle is used to assess tooth vitality. Presence or absence of a wave form can indicate the status of the tooth Plethysmography

47. The medical CT scanner was developed in the late 1960s, and subsequently patented by Hounsfield (1973) Trope et al in 1989. The lesions were differentiated on the basis of radiographic densities between the content of the cyst cavity and granulomatous tissue. The CT scan measures the x-ray attenuation in terms of HU. Hounsfield is used to describe the amount of x-ray attenuation of each voxel (volume element) in 3-dimensional image obtained by CT scan. Computed Tomography

48. The voxels are normally represented as 12-bit binary numbers, and therefore have 4096 possible values. These values are arranged on a scale from -1024 HU to +3071 HU, calibrated so that -1024 HU is the attenuation produced by air and 0 HU is the attenuation produced by water. Tissue fluids and soft and hard tissues produce attenuations in the positive range.

49. In the late 1990s Italian and Japanese groups (Arai et al. 1999, Mozzo et al. 1998), The X-ray beam is cone-shaped (hence the name of the technique), and captures a cylindrical or spherical volume of data, described as the field of view. CBCT has a rapid scan time of 10-70 secs . The spatial resolution of CBCT images (0.4mm to 0.076mm or equivalent to 1.25 to 6.5 line pairs/mm¯¹. Cone Beam Computer Tomography

50. Cone Beam Computer Tomography

51. Cone Beam Computer Tomography Sagital Axial Coronal

52. Internal resorption of the maxillary Right incisor and External cervical resorption of the maxillary left Incisor teeth

53. Magnetic Resonance Imaging MRI uses nonionizing radiation from the radiofrequency (RF) band of the electromagnetic spectrum. To produce an MR image, the patient is placed inside a large magnet, which induces a relatively strong exter­nal magnetic field. This causes the nuclei of many atoms in the body, including hydrogen, to align them­selves with the magnetic field.

54. After application of an RF signal, energy is released from the body, detected, and used to construct the MR image by computer. The high contrast sensitivity of MRI to tissue differences and the absence of radiation exposure are the reasons MRI for the most part have replaced CT for imaging soft tissue. CT remains an important technique for imaging bony tissues.

55. Applications: Imaging of the jawbones, including teeth, pulp spaces and periapical tissues. Pulps were better visualized after administration of a contrast medium. In detection of periapical pathosis . Edema in the periapical region is detectable. Any interruption of the cortical plates is also easily seen. Areas of bone sclerosis, which usually surround the periapical lesion, are seen as very low signals (black).

56. Ultrasound Real Time Imaging Real time echotomography or echography . Producing a sound wave A sound wave is typically produced by a piezoelectric transducer  encased in a housing which can take a number of forms. Strong, short electrical pulses from the ultrasound machine make the transducer ring at the desired frequency. The sound is focused either by the shape of the transducer, a lens in front of the transducer, or a complex set of control pulses from the ultrasound scanner machine.

57. This focusing produces an arc-shaped sound wave from the face of the transducer. The wave travels into the body and comes into focus at a desired depth. In addition, a water-based gel is placed between the patient's skin and the probe. The sound wave is partially reflected from the layers between different tissues.

58. Receiving the echoes The return of the sound wave to the transducer results in the same process that it took to send the sound wave, except in reverse. The return sound wave vibrates the transducer, the transducer turns the vibrations into electrical pulses that travel to the ultrasonic scanner where they are processed and transformed into a digital image.

59. Displaying the image Images from the sonographic scanner can be displayed, captured, and broadcast through a computer using a frame grabber to capture and digitize the analog video signal. The captured signal can then be post-processed on the computer itself.

60. When an area in a given tissue has high echo intensity – HYPERECHOIC Low echo intensity – HYPOECHOIC Absence of echo intensity – ANECHOIC Any fluid filled area where no reflection occurs in anechoic, whereas bone, from total deflection occurs is hyperechoic .

61. The interpretation of grey values on an image is based on a qualitative comparison of the echo intensity with that of normal tissue.

62. Application: Diagnosis & follow-up of extensive periapical lesions. Information on the size of the lesion and has a low radiation risk. It has a potential to describe the contents of the lesions (i.e. watery versus corpuscolated ) Their vascularization may become an important factor when making a differential diagnosis between lesions of endodontic origin (i.e. granulomas versus cysts) and also between other lesions of the maxillary bones. Ultra-sound guided BIOPSY.

63. They concluded Conventional and digital radiography enable diagnosis of periapical diseases, but not their nature, whereas ultrasound provides accurate information on the pathologic nature of the lesions, which is of importance in predicting the treatment outcome. Therefore ultrasound can be used as an adjunct to conventional or digital radiography in diagnosing periapical lesions. Comparison of the efficacy of conventional radiography, digital radiography, and ultrasound in diagnosing periapical lesions Namita Raghav et al oooe 2010

64. It uses similar sending/receiving probes as conventional LDF, but the probes are separate. Thus the laser beam is passed through from the labial or buccal side of the tooth to the receiver probe which is situated on the palatal or lingual side of the tooth. The limitations -where obstruction and/or interference from within the tooth structure will affect the results. Transmitted Laser Light

65. The assessment of pulp is a crucial diagnostic procedure in the practice endodontics . Pulp tests include sensibility and vitality tests. It is essential that clinicians understand the limitations of these tests and their usefulness. They are important diagnostic aids; however, their results must be interpreted in conjunction with consideration of: a detailed history, the symptoms, the clinical findings, radiographic observations & judicial use of advanced diagnostic aids. A diagnosis can only be reached once all the information has been gathered and assessed Conclusion

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67. Patrick Tsai, Mahmoud Torabinejad,Dwight Rice, and Bruno Azevedo . Accuracy of Cone-Beam Computed Tomography and Periapical Radiography in Detecting Small Periapical Lesions. Journal of Endodontics 2012;38:965–970. Namita Raghav , Sujatha S. Reddy, A. G. Giridhar , Srinivas Murthy, Yashodha Devi B. K,,N. Santana, N. Rakesh , MDS,and Atul Kaushik . Comparison of the efficacy of conventional radiography, digital radiography, and ultrasound in diagnosing periapical lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:379-385. Velayutham Gopikrishna , Gali Pradeep and Nagendrababu Venkateshbabu Assessment of pulp vitality: a review. International Journal of Paediatric Dentistry 2009; 19: 3–15 Thomas R. Pitt Ford & Shanon Patel. Technical equipment for assessment of dental pulp status. Endodontic Topics 2004, 7, 2–13.

68. Eugene Chen and Paul V. Abbott. Evaluation of Accuracy, Reliability, and Repeatability of Five Dental Pulp Tests. Journal of Endodonics 2011;37:1619–1623. Hamid Jafarzadeh , and Paul A. Rosenberg. Pulse Oximetry : Review of a Potential Aid in Endodontic Diagnosis. Journal of Endodontics 2009;35:329–333. Eugene Chen and Paul V,Abbott Dental Pulp Testing: A Review. International Journal of Dentistry 2009. E. Smith, M. Dickson, A. L. Evans,D . Smith & C. A. Murray .An evaluation of the use of tooth temperature to assess human pulp vitality. International Endodontic Journal, 37, 374–380, 2004. D. Evans, J. Reid, R. Strang , andD . Stirrups , “ A comparison of laser Doppler flowmetry with other methods of assessing the vitality of traumatised anterior teeth,” Dental Traumatology , vol. 15, no. 6, pp. 284–290, 1999

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70. Thank you