Examination of pulp (endo)
Formulating a diagnosis is part of a sequence of steps or procedures which can be referred to as the “diagnostic process.”
There are 11 stages 1. History taking—medical, dental, and the presenting complaint 2. Clinical examination 3. Clinical tests 4. Taking and interpretation of radiographs and/or other images 5. Formulating the diagnosis/diagnoses 6. Identifying the cause(s) of the disease(s) 7. Assessing the management options 8. Discussion with the patient 9. Finalizing the management plan with the patient’s consent 9. Tooth investigation—suitability for restoration/case selection 10. Records—note all findings and discussions in the patient’s clinical record
General medical history As required for all dental procedures Presenting complaint Long- and short-term history Past and current symptoms Past and recent treatment Medications being used (prescribed, self-prescribed, alternative) Description of PAIN: location, onset, nature, duration, stimuli, relief, referred Clinical examination Visually examine tissues for puckering, indentation, draining sinus, facial asymmetry, swelling, etc. Probe pits, fissures, grooves and tooth surfaces for caries Assess restorations and probe all margins Transillumination of the tooth with a fibre-optic light (re cracks) Periodontal probing Mobility Biting on individual cusps (e.g., with a ‘Tooth Slooth’, ‘FracFinder’) Clinical tests Pulp sensibility tests Periradicular tests Radiographic examination Tooth investigation Cold (e.g., CO2—dry ice) Electric Heat (if required, e.g., when only complaint is sensitivity to heat) Percussion Palpation Periapical radiographs (all cases) Other images may be required for some cases (e.g., tube shift periapical radiographs, bitewing radiographs, occlusal radiograph, panoramic radiograph, CT scans, etc.) Remove all restorations, caries, cracks Transillumination of the cavity, cusps, marginal ridges, etc. Assess whether, and how, the tooth can be restored again Assess the need for any other treatment (e.g., periodontal) Assess the long term prognosis of the tooth (consider endodontic, periodontal and restorative aspects)
General medical history¶
The Presenting Complaint The patient should be questioned about why they have attended for dental treatment. If the patient is presenting for a general or regular check-up, then there may not be a particular problem that needs special assessment. However, if the presenting problem is pain or a “toothache,” then further details are required.
General (or open-ended) questions should be used initially to encourage the patient to describe the pain or presenting problem in his/her own words.
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The Clinical Examination
There are two aspects to consider—the first is whether the pulp responds to the stimulus, while the second is the nature of the response. If a tooth does not respond to the stimulus, then this suggests that the pulp is necrotic or the root canal system has become pulpless and infected. In contrast, if a tooth does respond to the stimulus, then the pulp is either “clinically normal” or it has some form of pulpitis. The nature of the response will then determine the diagnosis—if the response is “normal” (compared to other teeth in that same patient’s mouth), then the pulp is likely to be “clinically normal.” However, if the response is exaggerated and the test reproduces the pain that the patient has been experiencing, then the general diagnosis will be pulpitis. The clinician must then determine what type of pulpitis—this is based on the history, the duration and the nature of the pain.
Pulp sensibility test¶
The latter two aspects can be reproduced by the pulp sensibility test (especially a cold test) that then leads to the diagnosis. There are three types of pulp sensibility tests commonly used in dental practice. They are cold, heat and electric tests. It is important to note that all pulp tests should be performed and interpreted in conjunction with all other clinical findings and periapical radiographs. If other information and radiographs are not available, then the pulp tests may not be meaningful—for example, a tooth may not respond to a cold pulp test because it has PCC that can only be determined radiographically. Another example is a tooth that does not respond to both cold and electric pulp tests because it has had previous root canal treatment—the presence of the root canal filling can only be noted radiographically or sometimes by clinically observing a typical endodontic access cavity restoration in the tooth.
Chen and Abbott35 compared CO2, electric, cold spray(EndoFrost), ice tests and laser Doppler flowmetry.
Percussion¶
The percussion test is a simple means of assessing whether there is inflammation or other changes occurring in the periradicular tissues. It is an indirect test in that the periradicular tissues themselves are not directly contacted by the test. Instead, the tooth has a force applied to it via percussion and this force is transmitted through the tooth to the surrounding tissues. Percussion testing does not specifically indicate periapical changes in all cases as inflammation or changes anywhere along the entire length of the tooth root can produce different responses to the percussion test.
• “Normal”—the same feeling as that patient’s other teeth, and with no tenderness or pain; this typically indicates clinically normal periradicular tissues (as long as there are no other signs or symptoms to suggest otherwise). • “Tender”—a painful response when percussing the tooth; this typically indicates secondary acute apical periodontitis or a secondary acute apical abscess. • “Very tender”—very painful response on percussion of the tooth; this typically indicates primary acute apical periodontitis or a primary acute apical abscess. • “Different sensation”—the patient reports that the tooth feels “different” on percussion compared to how the adjacent teeth felt—it is not painful or tender; this typically indicates chronic apical periodontitis or a chronic apical abscess. • “Ankylosis sound”—there is no pain but percussion produces a dull sound that is different from that produced when percussing the adjacent teeth—there is usually decreased mobility of the tooth also; this indicates the tooth has ankylosis and it may also have external replacement resorption (or possibly another form of resorption). A detailed history should help to determine why there is ankylosis.
Palpation¶
Palpation of the soft and hard tissues overlying the tooth can provide information regarding the periradicular status of the tooth. In the normal, healthy situation, palpation does not cause any discomfort. However, if there is inflammation present, then palpation may produce discomfort or even pain. Pain is more likely when there is swelling of the mucosa overlying the tooth root.
• “Normal”—the same as the other teeth for that patient, with no tenderness or pain; this typically indicates clinically normal periradicular tissues (as long as there are no other signs or symptoms to suggest otherwise) • “Tender”—painful response when palpating the mucosa overlying the tooth root and/or the periapical region; this typically indicates secondary acute apical periodontitis or a secondary acute apical abscess. • “Very tender”—very painful response when palpating the mucosa overlying the tooth root and/or the periapical region; this typically indicates primary acute apical periodontitis or a primary acute apical abscess. • “Hard swelling or expansion”—the tissues overlying the root and/or periapical region appear to be swollen or the cortical plate has expanded; the region feels hard on palpation. • “Soft swelling”—the tissues overlying the root and/ or periapical region are swollen; the region feels soft on palpation. • “Soft fluctuant swelling”—the tissues overlying the root and/or periapical region are swollen and fluctuant; the region feels soft on palpation as though the swelling contains fluid.
Periodontal Probing¶
Periodontal probing is an essential part of the diagnostic process for pulp, root canal, and periradicular diseases.
However, it is often not performed by clinicians especially if they do not think that the patient has generalized periodontal disease. However, the lack of periodontal probing may mean that an important piece of information is missed and this may in turn lead to misdiagnosis of the presenting complaint.
Periodontal probing is performed for two main reasons— first to assess the overall periodontal status of the dentition and in particular the individual tooth with the problem. The second reason is to check for the presence of a deep, narrow pocket that could be associated with an infected root canal system, a draining sinus, concurrent endodontic and periodontal diseases, or a crack in the tooth roots.
The probing depths at the six points (MB, B, DB, DLi, Li, and MLi) assessed for periodontal disease should be recorded and a note made to indicate that no other pockets were found. Alternatively, if one or more pockets are found, then the exact location(s), the depth(s) and the nature of the pocket (narrow, broad) should be recorded in the patient’s clinical record.
Mobility¶
The mobility of teeth should be assessed for two main reasons—first, it can provide information about the periodontal status of the tooth, and second, it indicates whether
Horizontal/lateral mobility implies movement in the buccolingual or mesiodistal direction. This can be assessed by using the handles of two instruments with one instrument on the labial/buccal surface and the other on the lingual/ palatal surface (Figure 8-28); then push against the tooth with one instrument at a time. Movement can be detected by the instrument on the opposite side of the tooth. Repeat from the opposite direction and then do this several times to gauge how far the tooth moves in each direction. Vertical mobility should also be tested and this is easily achieved by pushing the tooth from the occlusal or incisal direction using the end of the mirror handle. The depth of intrusion and subsequent extrusion of the tooth should be noted. The Miller Index49 is the most common system used to grade tooth mobility. There are various descriptions of this Index in the literature but the most common50 is • Grade 0: Normal (or physiological) mobility for the particular patient and when compared to that patient’s other teeth. • Grade I: Increased horizontal/lateral movement up to 1 mm. • Grade II: Increased horizontal/lateral movement exceeding 1 mm. • Grade III: Severe horizontal and vertical (depression) movement and/or rotation of the tooth.
Radiographic¶
Transillumination
biting test¶
Cusp flexure (associated with a crack undermining the cusp) ◊ The pain is usually sharp in nature and only momentary; it does not occur every time the patient bites on the tooth and typically only occurs when hard objects are bitten in a particular direction (with the direction of biting depending on the position and direction of the crack). • Apical periodontitis (especially acute apical periodontitis) ◊ The pain is not sharp although it can be severe (e.g., when primary acute apical periodontitis is present); the pain is present every time the patient bites or chews on the tooth. • Apical abscess (especially an acute abscess) ◊ The pain is not sharp although it can be severe (e.g., when a primary acute apical abscess is present); the pain is present every time the patient bites or chews on the tooth. • Lateral periodontitis (associated with a crack, a fracture or a periodontal abscess). ◊ The pain is not usually sharp but it can be sharp at times (e.g., when a root fracture is present); the pain is present every time the patient bites or chews on the tooth; the tooth will usually have a periodontal pocket and/or swelling on the lateral aspect of the tooth rather than apically; the tooth will have tenderness to palpation of the lateral aspect of the tooth rather than over the periapical region.