Diagnostic Aids in Endodontics

This scholarly presentation delves into the array of diagnostic aids currently revolutionizing the field of endodontics. From cone-beam computed tomography (CBCT) to advanced pulp vitality tests, the talk evaluates the accuracy, efficacy, and limitations of various diagnostic tools. It will discuss their integration into a coherent diagnostic workflow, supported by the latest research and technological advancements. This presentation is crucial for endodontists, oral radiologists, postgraduate dental students, and researchers interested in leveraging precise diagnostic tools for improved clinical outcomes in endodontic care.

1. DIAGNOSTIC AIDS IN ENDODONTICS Presented by – Dr. Ishaan Adhaulia

2. CONTENTS Diagnosis? Diagnostic Workflow History and Record All About Pain The Diagnostic Aid Pool Conventional Diagnostic Aids Neural Sensitivity Tests Pulp Vascularity Tests Recent Diagnostic Aids Conclusion References 2

3. What is Diagnosis? Diagnosis is the correct determination, discriminative estimation, and logical appraisal of conditions found during examination as evidenced by distinctive signs, marks, and symptoms . Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr. 3

4. Diagnostic Workflow Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr. 4

5. History and Record Case History Chief Complaint History of Present Illness Previous Dental History Medical History Personal Dental History Clinical Examination Intraoral Examination Investigations Final Diagnosis Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr. 5

6. Chief Complaint Main complaint or concern of the patient In patients’ own words Patient is encouraged and guided to discuss all aspects of current problem History taking and clinical examination in dentistry. Charu M Marya , (2014) 6

7. Maheswaran T, Ramesh V, Krishnan A, Joseph J. Common chief complaints of patients seeking treatment in the government dental institution of Puducherry, India. J Indian Acad Dent Spec Res. 2015 Jul 1;2(2):55-8.

8. History of present illness Severity and Urgency of the problem Site of pain Mode of onset Duration of pain Types of pain Progression of pain S.O.C.R.A.T.E.S History taking and clinical examination in dentistry. Charu M Marya , (2014) Nature of pain Aggravating Factors Relieving Factors Radiation of pain

9. Dental History Frequency of past visits Previous restorative, periodontic, endodontic or oral surgical treatments Reasons for loss of teeth Fluoride History Attitude towards previous dental treatment History taking and clinical examination in dentistry. Charu M Marya , (2014) Frequency of Dental Prophylaxis

10. Medical History Identification of any condition that may complicate or contraindicate the proposed dental treatment Communicable Diseases Allergies from certain drugs Systemic diseases History taking and clinical examination in dentistry. Charu M Marya , (2014) Drug History

11. Personal Dental History Oral Habits Oral Hygiene Habits Diet History Adverse Habits History taking and clinical examination in dentistry. Charu M Marya , (2014)

12. Clinical Examination Visual Inspection Palpation Auscultation Olfaction Percussion Aspiration History taking and clinical examination in dentistry. Charu M Marya , (2014)

13. Extra-Oral Examination Skin Lips Face TMJ Lymph Nodes History taking and clinical examination in dentistry. Charu M Marya , (2014)

14. Intra-Oral Examination History taking and clinical examination in dentistry. Charu M Marya , (2014) Lips / Labial Mucosa Buccal Mucosa Tongue Tonsils & Oro-Pharynx Hard Tissue Examination

15. History & Record Symptoms Subjective Objective

16. History & Record Diagnosis Differential Diagnosis Diagnosis by Exclusion Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr. Provisional Diagnosis

17. All About Pain An unpleasant or sensory emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP 2020) Pulpal pain KIND LOCATION DURATION Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr.

18. All About Pain KIND LOCATION DURATION Sharp, Piercing, Lancinating (reversible pulpitis) Dull, Boring or Gnawing (irreversible pulpitis) Localized Pain (Reversible Pulpitis) Diffused Pain (Irreversible Pulpitis) Short and Specific to stimuli (Reversible Pulpitis) Persistent & Lingering pain (Irreversible Pulpitis) Spontaneous Pain (Irreversible Pulpitis) Nocturnal / Postural Pain (Irreversible Pulpitis) Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr.

19. The Diagnostic Aid Pool Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr. CONVENTIONAL Visual & Tactile Inspection Percussion Palpation Mobility & Depressibility Bite Test RADIOGRAPHIC Intraoral periapical radiographs Bitewing Radiographs Digital Radiography Cone Beam Computed Tomography ASSESSMENT OF PULP VITALITY NEURAL SENSIBILITY TESTS Thermal Tests 1.1) Heat Testing 1.2) Cold Testing Electric Pulp Test Anesthetic Test Test Cavity PULP VASCULARITY TESTS Pulse Oximetry LASER Doppler flowmetry Recent Technologies 3.1) Dual Wave Spectrophotometry 3.2) Thermography 3.3) Crown Surface Temperature 3.4) Transmitted Light Photoplethysmography

20. Conventional Methods Visual and tactile inspection Percussion Palpation Mobility and Depressibility Bite Test Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr.

21. Visual & Tactile Inspection The most simple yet essential diagnostic test Casual examination = Loss of information Three ‘C’ Inspection : Colour / Contour / Consistency Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr.

22. Normal Vital Tooth Non-Vital Tooth Discolouration due to old amalgam filling Crack developing on marginal ridge & extending into the pulp chamber HARD TISSUES Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr.

23. Normal Contour, Colour & Consistency of Gingiva Inflamed gingiva losing its contour, colour & consistency Sinus Tract Parulis Detection of origin of sinus tract Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr.

24. Tactile Examination Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)

25. Palpation Test done with fingertips What do we get to know ? Whether the tissue is fluctuant & enlarged enough for incision and drainage Presence, intensity and location of pain Presence and location of adenopathy Palpation tenderness decreases in mandibular molars Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr. Submandibular Lymph Nodes Infected Submental Lymph Nodes Infected

26. Percussion Testing Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011) Apical Pathology Periodontal Pathology Symptomatic of Standardization of force

27. Percussion Testing Bruxism Sensitive to percussion in one direction Periodontitis Sensitive to percussion in any direction Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)

28. Bite Pressure Test Pt. c/o of having difficulty to chew from one side of the mouth Percussion test is not useful Bite test performed on such patients Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011) “Tooth Slooth ” (Professional Results Inc., Laguna Niguel, CA, USA) Wooden Stick

29. Mobility Testing A result of The mobility test is used to evaluate the integrity of the attachment apparatus surrounding the tooth Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr. Periodontally Sound

30. Millers Mobility Tooth Index Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr. First Degree Mobility Second Degree Mobility Third Degree Mobility

31. Depressibility Testing Test for depressibility is performed by applying pressure in the apical direction on the occlusal or incisal aspect of the tooth and observing vertical movement if any Periapical granulomas have a characteristic positive response to depressibility tests Endodontic treatment should NOT be carried out in such teeth Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr.

32. Radiographic Methods Intra-Oral Periapical Radiographs Bitewing Radiographs Digital Subtraction Radiography Cone Beam Computed Tomography

33. Intra-Oral Periapical Radiographs Intra Oral Peri Apical Radiographs – Diagnosis of caries since times immemorial It should not be the expectation that every pulpally involved tooth will have radiographic signs of pathosis. Proximal caries in maxillary second premolar Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)

34. Radiographic Applications in Endodontics Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr. According to Walton & Gomez :

35. Bitewing Radiographs White, Stuart C., and Michael A. Pharoah. Oral Radiology: Principles and Interpretation. St. Louis, MO: Elsevier, 2015. Interproximal Caries Crowns and alveolar crest of maxillary and mandibular teeth DIAGNOSTIC OBJECTIVES

36. Digital Subtraction Radiography Images of low diagnostic value are reduced Changes in radiograph can be precisely detected Picture of radiograph taken using high quality video camera , then fed into a computer called ‘digitizer’ Two radiographs with identical exposure are used, one called ‘ reference image ’, other taken for comparision . Both images are superimposed , differences between the two can be seen as dark areas.

37. Digital Subtraction Radiography

38. Cone Beam Computed Tomography Most significant technological advancement in in maxillofacial imaging Acquires data volumetrically providing 3D radiographic imaging Recordings reconstructed in Voxels White, Stuart C., and Michael A. Pharoah. Oral Radiology: Principles and Interpretation. St. Louis, MO: Elsevier, 2015.

39. Cone Beam Computed Tomography Assessment of the outcome of the root canal treatment de Paula-Silva et al evaluated periapical repair after root canal treatment in using CBCT and Periapical radiographs Six months after treatment, a favourable outcome was detected in 79% of teeth assessed with periapical radiographs in comparison to 35% when CBCT was used

40. Cone Beam Computed Tomography Assessment of Dental Trauma and Extent of Lesions The absence of radiographic signs when the X-ray beam is not parallel to the plane of the root fracture, tooth displacement and/or alveolar bone fracture is a limitation of intra-oral Periapical radiographs Horizontal root fractures usually affect maxillary central incisors and are typically traumatic in origin, associated with accidents, sports injuries or fights

41. Cone Beam Computed Tomography

42. Applications in Endodontics Extra canals and suspected complex morphology Localization of calcified canals Detection of vertical root fracture Assessment of endodontic treatment complications Presurgical treatment planning Localization and differentiation of external and internal resorptive defects White, Stuart C., and Michael A. Pharoah. Oral Radiology: Principles and Interpretation. St. Louis, MO: Elsevier, 2015.

43. Neural Sensibility Tests Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr.

44. Heat Test Flow of dentinal fluid towards pulp Salgar AR, Singh SH, Podar RS, Kulkarni GP, Babel SN. Determining predictability and accuracy of thermal and electrical dental pulp tests: An in vivo study. Journal of Conservative Dentistry: JCD. 2017 Jan;20(1):46. 65.5 Celsius 5 seconds Not as accurate as Cold Test Gutta Percha Stick / Ball Burnisher / Prophy Cup without water Positive Pressure C- fibres stimulated

45. Cold Test Ice Sticks / E thyl C hloride / DichloroDifluoroMethane / Dry Ice Positive Pressure Isolate the tooth Cotton Pellet to be used Endo Frost (-50*C) TFE (-26*C) Salgar AR, Singh SH, Podar RS, Kulkarni GP, Babel SN. Determining predictability and accuracy of thermal and electrical dental pulp tests: An in vivo study. Journal of Conservative Dentistry: JCD. 2017 Jan;20(1):46. 15 seconds

46. Anesthetic Test / PDL Shot Performed when all other tests have failed Anesthetizing one tooth at a time until pain is localized to a specific tooth If pain cannot be identified as from maxillary or mandibular origin – nerve blocks are given Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr.

47. Electric Pulp Test Uses Nerve Stimulation Unreliable for immature permanent teeth Uses Nerve Stimulation Normal Negative Positive Early Delayed False Positive & False Negative Not done in full coverage restorations Sui H, Lv Y, Xiao M, Zhou L, Qiao F, Zheng J, Sun C, Fu J, Chen Y, Liu Y, Zhou J. Relationship between the difference in electric pulp test values and the diagnostic type of pulpitis. BMC Oral Health. 2021 Dec;21(1):1-0.

48. Pulp Vascularity Tests Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr. Dental Pulse Oximetry Laser Doppler Flowmetry

49. Dental Pulse Oximetry Non-invasive method to measure oxygen saturation levels of blood Works on the principle of light absorption by blood and analyzing the relationship between the pulsatile changes of absorption NOT COMMERCIALIZED YET

50. Principle of Dental Pulse Oximetry POS POM Photodetector Red + Infrared light Units consists of POS + Photodetector + POM POS = red light (660nm) + infrared light (940nm) Oxygenated and De-Oxygenated blood absorbs different amounts of red & infrared light Pulsatile change in the blood volume causes periodic changes in the amount of red and 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 analyzed by the pulse oximeter to determine the saturation of arterial blood. Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr.

51. Laser Doppler Flowmetry Non Invasive Method Measures rate of blood flow in a microvasculature Continuous Real-Time Readings largely dependent on the linearity of the flowmeter output to the changes in the RBC Flux Red He-Ne gas lasers & Near Infrared Diode Lasers used COSTLY Depth penetration of N.I.R Diode lasers is more compared to He-Ne Lasers Obeid AN, Barnett NJ, Dougherty G, Ward G. A critical review of laser Doppler flowmetry. Journal of medical engineering & technology. 1990 Jan 1;14(5):178-81.

52. Principle of Laser Doppler Flowmetry Laser light transmitted through fiberoptic source and placed on tooth surface Light enters RBC’s which leads to shift in frequency of scattered light The proportion of frequency shift is detected by a photodetector Detection of blood movement through pulp space done Parameswaran, A.   "Grossman's endodontic practice - 14th edition." Endodontology, vol.   33, no.   2, Apr.

53. Recent Diagnostic Aids in Endodontics Computed Infrared Thermographic Imaging Tuned Aperture Computed Tomography Fiber -optic Trans-illumination Method Thermistor Orascope

54. Computed Infrared Thermographic Imaging Measures the surface temperature of tooth accurately Temperature can be measured from a distance Accurately indicates pulpal blood flow Camera is capable of detecting temperature changes as small as 0.1 degree Celsius Non - Invasive Real Time Data Saxena AS, Patle B, Lambade P. Advanced diagnostic aids in endodontics. Journal of Indian Academy of Oral Medicine and Radiology. 2011 Jul 1;23(3):221.

55. Tuned Aperture Computed Tomography Works on the basis of Tomosynthesis Less distortion and anatomical noise Overall radiation dose not more than 1-2 times of a conventional IOPA Studies were conducted wherein TACT was more diagnostically accurate over conventional 2D IOPA’s Detected 36% more extra Mesio -Buccal canals in Maxillary first molars and 80% more Mesio -lingual canals in mandibular molars Excellent for vertical root fracture detection Saxena AS, Patle B, Lambade P. Advanced diagnostic aids in endodontics. Journal of Indian Academy of Oral Medicine and Radiology. 2011 Jul 1;23(3):221.

56. Fiber Optic Transillumination Extremely useful in detecting coronal fracture lines Dry the tooth - fibre-optic probe of 0.5mm placed in the buccal or lingual embrasure between two adjacent teeth . 150 Watt Halogen Lamp with a Rheostat Carious Lesions – Dark Shadows No Hazards

57. Applications of FOTI in Endodontics Strassler HE, Pitel ML. Using fiber-optic transillumination as a diagnostic aid in dental practice. compendium. 2014 Feb;35(2):80-8.

58. Thermistor Small Thermometer – can detect minute temperature changes Even a drop of saliva can change the thermal readings Vital teeth rewarm to normal temperature after intentional cooling below room temperature Non vital teeth cannot regain the same temperature once cooled Thermistor measures this change in temperature Measuring thermistor – surface temperature of enamel Reference thermistor – atmospheric temperature Soyenkoff BC, Okun JH. Thermal conductivity measurements of dental tissues with the aid of thermistors. The Journal of the American Dental Association. 1958 Jul 1;57(1):23-30.

59. Orascope Flexible fiberoptic intracanal visualization device Has a 0.8mm tip 1:1 image to sensor ratio Working portion 15mm in length Useful in identifying intracanal anatomy Abnormalities in root canals Root canal calcifications No Radiation Not commercialized yet Pandey D, Chaturvedi P, Shuklai V. Recent Diagnostic Aids in Endodontics.

60. Conclusion I n this era when the science has an immense growth in all fields, the incorporation and utilization of the advanced technologies in the field of diagnosis has proved to be a great achievement in the field of medical and dental sciences. The enhanced diagnostic approach includes enhanced visualization tools to detecting the changes at cellular and molecular level. Ultimately the goal of all health care professional is to provide better treatment and improve the quality of life.

61. Bibliography

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