7. DIAGNOSTIC PROCEDURES IN ENDODONTICS.pptx

7. DIAGNOSTIC PROCEDURES IN ENDODONTICS.pptx

1. Endodontic diagnosis- PART 2 Dr. Sushmita Rane Seminar- 7 6/02/2023

2. INTRODUCTION STEDMAN’S MEDICAL DICTIONARY ‘clinical diagnosis is the determination of the nature of the disease made from a study of the signs and symptoms of the disease.’ Latin “ Diagignoskein ” Dia : apart Gignoskein : to learn

3. 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 the objective testings . The clinician correlates the objective findings with the subjective details and creates a tentative differential diagnosis. The clinician formulate a definitive diagnosis.

4. EVOLUTION Oldest tests : visual examination, percussion & palpation Early 1900s : X-rays, thermal vitality tests, EPT, mobility tests, test cavity & anesthetic test. Recent : Pulse oximetry, LDF, US, Fiberoptics, Thermographic imaging, Crown surface temperature, Photoplethysmography, RVG, CT, MRI

5. Uses Prior to operative procedures : Used for selected teeth prior to any restorative or orthodontic interventions, where pulp health may be in question Diagnosis of pain : Identifying pulpal pain from other conditions such as Myofascial pain dysfunction syndrome and referred pain Normal response to pulp testing - eliminate pulpal pathology Investigation of radiolucent areas : Periapical extension of pulpal pathology

6. PULP SENSIBILITY TESTS The typical tests used to assess pulps are either Thermal(cold, heat) or electric pulp tests – These all test depends on whether the pulp responds to the applied stimulus and hence they are Sensibility Tests

7. Uses of pulp sensibility tests Assess the health status of the pulp Locate and diagnose tooth with pulpitis Locate and diagnose tooth with necrotic pulp Follow up and monitor pulp after trauma Part of differential diagnosis process

8. Necrotic pulp Clinically normal/ Pulpitis Pulp Response to the stimulus Response Responds Nature of the response Normal (compared to other teeth) Exaggerated (Reproduces the pain that the patient has been experiencing- Pulpitis) What type of Pulpitis- History, duration, nature

9. THERMAL TESTS Application of heat / cold to a tooth to determine sensitivity to thermal changes. A response indicates a vital pulp, regardless of whether the pulp is normal / abnormal.

10. Mechanism of COLD sensibility pulp TEST

11. COLD Pulp sensibility TESTs

12. Dry ice Chen and abbott reported that Dry ice sticks were the most reliable cold test formed in the device called Odontotest This device uses pressurized liquid CO2 that is forced through a small orifice. It becomes Dry ice when it comes under atmospheric pressure This produces stick of dry ice. Its temperature is -56 °C when applied to the tooth

13. Refrigerant spray Endo ice- 1,1,1,2 tetrafluoroethane It has a temperature of about -26 °C when first sprayed but this reduces to about-18.5 °C in the mouth Application- sprayed on cotton pellet then applied to the tooth Disadvantage- becomes liquid quite rapidly in the warm environment of the mouth. The liquid can then flow in the gingival region where it may be felt and misinterpretated as being from pulp of the tooth Ice Used by freezing water in the local anesthetic catridge and then applying the extruded portion to the tooth

14. HEAT Pulp sensibility test Teeth with clinically normal pulp do not respond to heat- they only respond to heat when they are inflamed When do we use Heat test? patient’s chief complaint is intense pain on having hot liquid/food.

15. METHODS Ball burnisher Hot GP sticks Dry rubber polishing wheel Hot water

16. Technique

17. ELECTRIC PULP TESTING Uses nerve stimulation. Objective is to stimulate a pulpal response by subjecting the tooth to an increasing degree of electric current . Electric Pulp Tester (EPT) scale used : 0-64 units Healthy vital pulp : 11-16 units Sequence of testing :1st contralateral tooth 2nd opposing tooth 3rd adjacent tooth Last suspicious tooth

18. Technique

19. In case of complete coverage crown the tip of endodontic explorer is coated with toothpaste and placed in contact with the tooth structure The tip on the electronic pulp tester is placed on the explorer and checked for response

20. Response Interpretation Positive Vital Negative Non vital False negative Immature teeth, recent trauma, atrophied pulp/calcification, poor contact with tooth, inadequate electrolyte. False positive Patient anxiety, multirooted teeth, contact with metallic restoration Delayed respose (>30units) Partial necrosis Early/Exaggerated(10 or <) Hyperemia Responses of EPT

21. Contraindications : cardiac pacemaker & insulin pumps Teeth with full coverage restorations Disadvantages : Gives no indication of state of vascular supply. Doesn’t measure the degree of health /disease of pulp.

22. A study conducted by Peterson et al compared the ability of thermal and electric pulp testing methods in detection of pulp. The sensitivity of cold test was 0.83, 0.86 for heat testing and 0.72 for EPT. Same study evaluated the specificity of these tests. 93% of teeth were correctly identified by cold and EPT whereas only 41% teeth were identified by heat tests Results showed accuracy of cold test to be 86%,EPT 81%,heat test 71%

23. BITE TEST Useful in identifying a cracked tooth or fractured cusp, when pressure is applied in a certain direction to one cusp or section of the tooth. Methods used : Biting on Orangewood stick Wet cotton roll Burlew rubber disk

24. Many methods have been described to identify crack undermining the cusp. But the most common and generally used are Commercially available devices : Tooth slooth & FracFinder The test is repeated on each cusp and on several teeth in the region of patients complaint

25. How to distinguish between different conditions? Symptomatic Apical periodontitis Apical Abcess Lateral periodontitis (periodontal pocket, swelling and tenderness on palpation on lateral aspect) Cracked tooth or cusp flexure Pain on biting Pain on release of biting force

26. DYE / STAIN TEST Can be done individually or along with other tests. Used to determine the presence of crack in the surface of a tooth & caries detection

27. A small amount of dye is placed on a small cotton pellet & crown/root is coated with it. Any dye on surface is washed away & if fracture present , dye remains in the crack & can be observed via loupes Technique

28. FIBEROPTIC TRANSILLUMINATION An FOTI device can be used to confirm the presence of cracks underneath any restoration & to determine the extent & depth of the cracks Shining a bright light on the buccal / lingual surface of tooth. For a tooth that is not cracked, light will shine through the opposite surface without any interruption. Friedman & Marcus reported its usefulness for detection of proximal caries.

29. ANESTHETIC TEST Restricted to patients who are in pain at the time of the test when the usual tests have failed to identify the tooth.

30. TEST CAVITY Involves drilling through enamel-dentin junction of an unanesthetized tooth using high speed handpiece. Sensitivity/ pain felt by the patient indicates vital pulp – no endodontic treatment indicated cavity is restored. No pain felt : cavity preparation continued until pulp chamber is reached.

31. OCCLUSAL ANALYSIS Occlusion should be checked to determine if the offending tooth is in traumatic occlusion. Excessive occlusal forces can be the cause of pulpal inflammation.

32. GP Point tracing Can localize Endodontic lesion to a specific tooth Aids in the differential diagnosis between a periodontal and endodontic lesion Place a gutta percha point through the sinus/ Fistula tract and take a radiograph

33. ADVANCED DIAGNOSTIC AIDS

34. LASER DOPPLER FLOWMETRY Laser Doppler flowmetry (LDF) is a method used to assess blood flow in microvascular systems. The Doppler principle states that the light beam will be frequency-shifted by moving red blood cells but will remain unshifted as it passes through static tissue Uses HeNe (632.8nm) & GaAl semiconductor diode laser(780-820nm)

35. Optical measuring method- number and velocity of particles conveyed by fluid flow is measured Laser light is transmitted to the pulp by means of fibre optic probe

36. Technique

37. a) Painless b) Useful in traumatized tooth c) Used in patients who have undergone orthognathic surgery d) No noxious stimuli e) Can be used in both adults & children a) Technique sensitive b) Expensive c) Affected by antihypertensive drugs & nicotine d) Not useful in teeth with crowns/large restorations f) Detects only coronal blood flow of pulp

38. Ani Belcheva et al(2021) two groups: test group (44 traumatised teeth) and contro l group (44 sound and healthy teeth). The measurement of Pulpal Blood Flow was performed, using a LDF monitor The analysis of the LDF outcomes in function of diagnosis indicated that the measurements of the traumatised teeth were significantly higher than those of non-traumatised teeth (p < 0.05).

39. This study concluded that LDF application provides dentists with fundamental benefits in terms of an early and precise investigation of Pulpal Blood Flow . In addition, LDF is a useful monitoring tool for revascularization of traumatised teeth and reliable objective diagnostic indicator of pulp vitality.

40. PULSE OXIMETRY Noninvasive method to measure oxygen saturation levels. Sensor 2 LEDs Red light (660nm) Infrared light (940nm) A pulse oximeter works by transmitting light through translucent portion of body( eg. Finger, ear, tooth)

41. The amount absorbed depends on the ratio of oxygenated to deoxygenated hemoglobin in the blood. On the basis of difference between the light emitted and light received a microprocessor calculates the pulse rate and oxygen concentration It Transmits light through translucent portion of body Some of this light is absorbed as it passes through the tissue

42. Indications: Recent Trauma Primary and immature permanent teeth Patient monitoring: sedation Limitation: Intrinsic interference: Venous blood and tissue constituents, acidity, CO2 Extrinsic interference Well adapting sensor Hb bound to other gases Extensive Restorations Environmental-ambient light interference

43. Measurement of surface temperature

44. THERMISTOR The thermistor is a small, resistance thermometer with very high sensitivity and low heat capacity. Researchers have stated that a vital tooth and a nonvital teeth if cooled below room temperature it is seen that vital teeth rewarm back to the room temperature faster than the nonvital tooth 2 Types Measuring Thermistor Reference Thermistor

45. Banes & Hammond – evaluated accuracy of thermistor in teeth with vital pulps & previous RCT both with & without full gold crowns. Surface temp of RC treated teeth without full gold crowns were significantly lower than those of with vital pulps

46. CHOLESTERIC LIQUID CRYSTALS Howell et al employed color change of cholesteric liquid crystals in detecting pulp vitality. Used to show difference in tooth temp between teeth with vital (hotter) pulp & necrotic (cooler) pulp.

47. Technique

48. THERMOCOUPLE Thermocouples are used for measuring the tooth surface temperature. Brown and Goldberg et al using thermocouple found out that surface temperature decreased in an anterior direction. Labial surface had lesser temperature when compared to palatal surface.

49. Aidin Farugi et al(2021) This clinical study was designed to compare cold pulp testing (CPT), heat pulp testing (HPT) and electric pulp test (EPT) with pulse oximetry (PO), flowmetry(FM) and thermometry (TM) in terms of sensitivity and specificity

50. Methodology 20 Premolar teeth in need of Root canal treatment age between 20 and 50 years All tests (CPT, HPT, EPT,,FM, PO and TM) were performed by a single clinician. No response within 7 s was considered negative for both tests. The sequence of tests was EPT, CPT and finally HPT. Oxygen saturation percentage was measured for determining vitality; An infrared transmitter circuit was used for Flowmetry which detects the variations in blood volume. For Thermometry, temperature of two teeth was measured for each patient: the test and the control

51. HPT was the most accurate of all in diagnosing pulp status without any false results PO was the most accurate of all vitality tests This study suggests that Pulp sensibility tests may be more accurate than vitality tests and are reliable for pulp vitality assessment.

52. INFRARED THERMOGRAPHY Computer controlled infrared imaging system is a noninvasive sensitive method of measuring body temperature Vital pulp higher surface temp than necrotic pulp Components : IR sensor, control unit, thermal image computer, software, color monitor & printer

53. Technique

54. Sara Mendes et al in this study(2020) For the study group, 33 non-vital teeth and 33 vital upper central incisors were assessed. The inclusion criteria were: age between 20-65 years old; negative response to the vitality tests, teeth suspected to be in a necrotic pulpal state confirmed by periapical X-ray. They concluded that the use of IRT to assess humans anterior teeth temperature with different pulp states may present different temperatures. Thus, the results suggested that the use of IRT to assess a tooth’s vitality may be an aiding tool during a diagnostic exam.

55. HUGHES PROBEYE CAMERA It can detect temperature changes as small as 0.10°C. It can also measure pulp vitality, by measuring blood flow in pulp. This consists of thermal video system with a silicon close up lens with a resolvable spot size of 0.023 inch.

56. UV LIGHT Some objects possess an unusual feature of being able to emit light of higher wavelength when illuminated with UV light. This feature is called ‘Fluorescence’ Foreman et al (1983) reported that teeth with necrotic pulps & teeth with RCT did not fluoresce when exposed to UV light, while teeth with vital pulp fluoresced normally.

57. ULTRASOUND Ultrasound (US) is a non-invasive, inexpensive and painless imaging method. Tremendous potential to compliment conventional radiography as an imaging technique. High resolution : 3D images of inner macrostructures of tooth. Based on the reflection (echoes) of ultrasonic waves at the interface b/w tissues having different acoustic properties

58. Use of Ultrasound

59. The ultrasound apparatus incorporates

60. Technique

61. An area of tissue that causes a considerable reflection of ultrasound is described as Hyperechoic Solid lesion Biopsy An area where there is no reflection of echoes, typically within homogeneous liquids is Anechoic Cystic lesion Enucleation

62. Elisabetta Cotti et al (2020) Ultrasound real-time examination is a promising tool to detect and trace noninvasively sinus tracts of endodontic origin. It produces a direct image rather than one obtained with a gutta-percha cone inserted into the tract. The vascular reaction within and around the tract can be also observed by the 3D rendering and the color and power Doppler implementation.

63. 10 patients who had a lesion of apical periodontitis (AP) and Sinus tract and 10 patients in the control group with AP without an Sinus tract recruited in 2 endodontic practices. They also traced the pattern of the Sinus tracts with a computer program. The images were then submitted to 2 calibrated and blinded observers who were asked to describe the presence of AP and Sinus tract and to trace it with the same program. The data obtained were compared with the clinical and radiographic diagnosis of Sinus tract. Methology

64. The main application of ultrasound in dentistry in the past years has always been the diagnosis of pathologies of the major salivary glands, and sialolithiasis This examination, due to its reduced invasiveness and absence of radiation This major salivary glands may present with symptoms such as dry mouth, dysphagia and obstruction of duct, inflammation, or swelling

65. ULTRASOUND DOPPLER / COLOR POWER DOPPLER Ultrasound Doppler allows for the detection of the rate and direction of the blood flow. Intensity of Doppler signal is represented by changes in real time on a graph (Doppler) & also shown in form of color spots on gray scale image (color). Positive doppler shifts : blood moving toward transducer = RED Negative doppler shifts : blood moving in opposite direction = BLUE

66. Vital tooth : US doppler reveals a pulsating waveform & sound characteristic. Non vital tooth : Linear non-pulsed waveform without pulsating sound.

67. In this study, 30 patients having inflammatory periapical lesions of the maxillary or mandibular anterior teeth and requiring endodontic surgery were selected They used conventional periapical radiographs as well as USG with color Doppler and power Doppler for the diagnosis of these lesions. Their diagnostic performances were compared against histopathologic examination. Methodology

68. Figure 1 (A-C): Periapical cyst. A) Intraoral periapical radiograph shows a well-circumscribed radiolucent periapical lesion (arrow) with a partial sclerotic border, measuring more than 1 cm in diameter. B) USG with color Doppler and power Doppler shows a hypoechoic,well -contoured cavity (arrow) with no evidence of internal vasculature on color and power Doppler examinations. C)H and E stained section shows the presence of an epithelial lining (arrow) with underlying dense fibrocellular connective tissue stroma (arrowhead)

69. Figure 2 (A-C): Periapical granuloma. A)Intraoral periapical radiograph shows a well-circumscribed radiolucent periapical lesion (arrow) without a sclerotic border, measuring less than 1 cm in size. B)USG with color Doppler and power Doppler shows a poorly defined hypoechoic lesion (arrow) exhibiting a rich vascular supply on color and power Doppler examinations. C)H&E stained section shows fibrocellular connective tissue stroma (arrow) consisting of chronic inflammatory cell infiltrate and endothelium-lined blood capillaries with red blood cells, fibroblasts, and collagen fibers

70. The difference between the accuracy of radiographs and USG for the detection of periapical cyst and periapical granuloma proved to be highly significant ( P <0.001) USG with color Doppler and power Doppler is superior to conventional intraoral radiographic methods for diagnosing the nature of periapical lesions in the anterior jaws.

71. DUAL WAVELENGTH SPECTROPHOTOMETRY This method measures oxygenation changes in the capillary bed rather than in the supply vessels. Independent of pulsatile circulation Detects presence or absence of oxygenated blood at 760nm & 850nm It is useful method for testing vitality

72. PHOTOPLETHYSMOGRAPHY Optical measurement technique : used to detect blood volume changes in microvascular bed of tissue. Can also be used to investigate circulatory changes in pulp. Hb absorbs certain wavelengths of light, while remaining light passes through the tooth & is detected by a receptor.

73. Vital pulp : Pulsatile waveforms Non-Vital pulp : loss of pulsatile (Miwa et al,2002)

74. Recent advances in magnification ENDOSCOPE The use of the endoscope in endodontics was first described in 1979 as an aid in the diagnosis of root fracture of a maxillary central incisor It captures images of the subgingival environment on a real-time and has fiber optic–delivered camera LOUPES are magnification devices that are widely used in dental procedures that allow easy focus on the surgical field and that have been used to enhance visualization of tissues and to facilitate optimal instrument placement

75. MICROSCOPE It has also been used as a diagnostic tool in the detection of small orifices, in vertical root fractures and as a complementary tool in procedures such as repair of perforations and removal of obstacles inside the root canal .  ORASCOPY involves using the ORASCOPE , a modified medical endoscope, for treatment in the oral cavity. It uses fiber optics, making the instrument lightweight and flexible.

76. CONCLUSION Diagnosis forms the basis of treatment. The techniques of endodontic diagnosis are ever evolving. Careful attention to diagnostic aids & an understanding of both their usefulness & limitations is essential. The newer techniques gives more accurate and clear diagnosis about status of the dental disease. Few systems are in their infancy and many are based solely in laboratories, however such technologies may prove useful in future.

77. REFERENCES COHEN-Pathways of the Pulp (11th Edition) INGLE- Endodontjcs (7th Edition). WEINE-Endodontic Therapy (Fifth Edition) Benjamin Salmon; Dominique Le Denmat (2012). Intraoral ultrasonography: development of a specific high-frequency probe and clinical pilot study. Dr.Divya Pandey,Dr Pooja Chaturvedi(2020)Recent Diagnostic Aids in Endodontics . Recent Advances in Endodontics Exploring the Trends in Diagnosis.(2020). International Journal of Innovative Science and Research Technology

78. Thank you