Dr.

Raghad Al-Hashimi
BDS, MSc, PhD (London, UK)

Assistant Professor / Department of

Restorative & Esthetic Dentistry

2018-2019

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 Endodontics
Lecture 1 Asst. Prof. Raghad Alhashimi

Endodontic Diagnosis & Treatment Plan

Diagnosis is the science of recognizing disease by means of signs, symptoms, and tests.
Often, diagnosis is straightforward; sometimes it is not. The basic steps in
the diagnostic process are as follows:

1. Chief complaint
2. History: medical and dental
3. Oral examination
4. Data analysis → differential diagnosis
5. Treatment plan

In other words, diagnosis is the procedure that accepts the patient and recognizes his/her
problem. Then, determining the cause of a problem and accordingly developing a treatment
plan to treat the problem.

Requirements of a diagnostician

1. Knowledge: A dentist must depend on himself and his scientific background.

2. Interest and curiosity: The dentist must be interested in solving the problem of the
patient and curios about the result of the diagnosis.
3. Patience: The dentist needs time and patience to understand the reasons of the problem
which not always are visible and needs some time and investigations to reveal the
cause of the problem.

Chief complaint. It is a description of the dental problem of the patient. The form of notation
should be in patient’s own words.

History
A complete medical history should contain the vital signs, give early warning of unsuspected
general disease and find risks to the health patient (during treatment) and the dental staff.

Present dental illness. Pain is the main reason for the patient's complaint. It ranges from dull
to severe which indicates the severity of the problem. It may indicate the source which may
be dental or the surrounding structures.

Medical history. It is very important in patients with medical problems that may interfere
with the dental treatment as history of bleeding, heart diseases, diabetes. Any medications
taken by the patient may affect the dental procedure as aspirin. There are no medical

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conditions which specifically contraindicate endodontic treatment, but there are several which
require special care. Scully and Cawson have given a checklist (Table below) of medical
conditions which are needed to be taken a special care.

Clinical examination
Examining the patient clinically with the patient's history will make the diagnosis of the
problem.

Vital signs
1- Blood pressure. The normal pressure is 120/80 mm Hg for patients under age of 60
years; 140/90 mm Hg for patients over the age of 60 years. Any pressure exceeding this limit
needs consultation with the cardiologist before dental treatment.
2- Pulse rate and respiration. The normal pulse rate is 60-100 beats/minute and the
respiration is 16-18 breaths/minutes. They may be elevated due to stress and anxiety.
3- Temperature. The normal temperature of the body is 37 oC (98.6 F). Any elevation in
the body temperature may be a sign of general illness.
4- Cancer screen. This examination should include the face, lips, neck and intraoral soft
tissues for lumps and white spots.

Extraoral examination
Inflammatory changes originating intraorally and observable extraorally may indicate a
serious spreading problem. The extraoral examination includes the face, lips and neck which
may need palpation. Painful and/or enlarged lymph nodes may indicate the spread of the
inflammation as possible malignancy. The extent and manner of jaw opening may give a sign
of possible myofacial pain and dysfunction. The following table shows the provisional
diagnosis after examination of lymph nodes:

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Intraoral examination
Before conducting intraoral examination check the degree of mouth opening. For a normal
patient it should be at least two fingers. The oral vestibules and buccal mucosa should be
examined for localized swelling and sinus tract or color changes. The lingual and palatal soft
changes should be then checked. Finally the teeth should be inspected for a carious lesion,
faulty restoration, loss of teeth, and presence of deciduous or supernumerary teeth.

Pulpal evaluation
There are many tests that indicate the pulpal health state. These tests reveal the extent of the
problem and give a clue about the treatment as irreversible pulpitis needs endodontic
treatment whereas reversible pulpitis may need a normal filling.
Pain history
Initially, information on pain is obtained by asking questions regarding the current
problem(s). This examination is subjective, frequently asked questions include:
● Location. Occasionally a patient may identify the location of the pain; however, one must
be cautious as pulpal pain may be referred to a different area. Pain may be felt in any of the
orofacial structures.
● Type and intensity of pain. The patient may describe pain in many ways. Examples include
sharp, dull, throbbing, stabbing, burning, electric shock like, deep or superficial. The more the
pain disrupts the patient’s lifestyle because of its intensity, the more likely it is to be
irreversible in origin.
● Duration. For how long after removal of the stimulus does the pain continue? The longer
the pain continues after the stimulus, the more likely it is to be irreversible.
● Stimulus. Many different stimuli may initiate the pain, for example hot, cold, sweet, biting,
posture. Alternatively the pain may be spontaneous. Special tests may be selected on the basis
of what causes the main complaint.
● Relief. Pain-relieving factors, especially type and frequency of analgesics, antibiotics,
sipping cold drinks.

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Periodontal evaluation
The complete diagnosis is performed when examination is done to the tooth and surrounding
tissues. The periodontal pathology as gingivitis and periodontal pockets may affect the pulp
therefore periodontal treatment may be necessary before/with the endodontic treatment.
Periodontal evaluation can be assessed from palpation, percussion, mobility of tooth and
probing

Clinical endodontic tests

For accurate diagnosis, evaluation of history, examination and clinical tests should be done
properly. Clinical examination of tissue is done by palpation, percussion and other endodontic
clinical tests. These tests provide us a clue about the expected condition of the tooth's pulp
and supporting structures. One test is not enough for a decisive diagnosis therefore a
combination of tests is necessary.

Thermal tests:
In thermal test, the response of pulp to heat and cold is noted. The basic principle for pulp to
respond to thermal stimuli is that patient reports sensation but it disappears immediately. Any
other type of response, i.e. painful sensation even after removal of stimulus or no response are
considered abnormal. .It is divided to cold and heat stimuli.

1. Cold testing. It differentiates between reversible and irreversible pulpitis and identifying
necrotic teeth. If a tooth is sensitive to a cold stimulus which subsides after removal of
stimulus then the condition is reversible. If the sensitivity takes time more than few seconds
then the condition may be irreversible. Teeth with calcified canals need more time for the cold
stimulus to reach the pulp. It is the most commonly used test for assessing the vitality of pulp.
It can be done in a number of ways. The basic step of the pulp testing, i.e. individually
isolating the tooth with rubber dam is mandatory. Use of rubber dam is especially
recommended when performing the test using the ice-sticks because melting ice will run on to
adjacent teeth and gingivae resulting in false-positive result. Cold testing may be done by air
blast, cold drink, ice stick or ethyl chloride.

2- Heat testing. Heat test is most advantageous in the condition where patient’s chief
complaint is intense dental pain upon contact with any hot object or liquid. The use of a hot
stimulus can help locate a symptomatic tooth with necrotic pulp. Heated gutta percha stick or
hot water may be used.

Percussion. This is used to find if the apical periodontium has been affected by the pulpal
pathology. Percussion can be carried out by gentle tapping with gloved finger, Or you can use
any hard instrument may be used to tap the incisal/occlusal surface of the tooth.

Pain on percussion is indicative of possibility of following conditions:

a. Periodontal abscess
b. Pulp necrosis (Partial or total)
c. High points in restorations
d. During orthodontic treatment

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Palpation. This test signals the further spread of inflammation from the periodontal ligament
to the periostium overlying the bone. This test checks for fluctuation and possible asymmetry
of the surfaces around the tooth.

Mobility
The mobility of a tooth is tested by placing a finger or blunt end of the instrument on either
side of the crown and pushing it and assessing any movement with other finger.and a note
made of the degree of movement: up to 1 mm scores 1, over 1 mm scores 2 and vertically
mobile teeth score 3.

Occlusal analysis
It is important to examine suspected teeth for interferences on the retruded arc of closure,
intercuspal position and lateral excursions. Interferences in any of these positions could result
in a degree of occlusal trauma and institute acute apical periodontitis.

Sinus tract exploration

Where a sinus tract is present, it may be possible to insert a small gutta-percha point. A
radiograph is then taken to see which root the tract/point leads to.

Transillumination
Transillumination with a fibre optic light show cracks in teeth. These cracks cause stretching
of the pulp tissues when a lateral pressure is exerted on the tooth therefore causing pain.

Periodontal probing
Detailed periodontal probing around suspected teeth may reveal a sulcus within normal limits.
However, deeper pocketing will be identified. A narrow defect may be an indication of a root
fracture or an endodontic lesion draining through the gingival crevice. This causes an
endodontic-periodontal lesion.

Radiographs
Radiographs should be taken using film holders and a paralleling technique and be viewed
using an appropriate viewer with magnification as necessary. They will not show early signs
of pulpitis as there is no periodontal widening at this stage of pulpal degeneration.
Radiographs may provide important information to
help confirm a diagnosis, but they should not be used
alone. Radiographic findings may include the loss of
lamina dura (laterally or apically) or a periradicular
radiolucency indicative of pulp necrosis.
Alternatively, radiographs may show pulp chamber or
root canal calcification, which may explain reduced
responses to pulp sensitivity testing. This emphasises
the need for considering using more than one test.
Radiographic examination may also reveal tooth/root
resorptive defects. In all endodontic cases, a good

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intraoral radiograph is mandatory as it gives excellent details and helps in diagnosis and
treatment planning.

Radiographs help us in following ways:

a. Establishing diagnosis
b. Determining the prognosis of tooth
c. Disclosing the presence and extent of caries
d. Check the thickness of periodontal ligament
e. To see continuity of lamina dura
f. To look for any periodontal lesion associated with tooth
g. To see the number, shape, length and pattern of the root canals
h. To check any obstructions present in the pulp space.
i. To check any previous root canal treatment if done
j. To look for presence of any intraradicular pins or posts
k. To see the quality of previous root canal filling
l. To see any resorption present in the tooth
m. To check the presence of calcification in pulp space
n. To see rootend proximal structures
o. Help in determining the working length, length of master gutta-percha cone and quality of
obturation
P. During the course of treatment they help in knowing the level of instrumental errors like
perforation, ledging and instrumental separation

Though the radiographs play an important role in dentistry, they have a few
shortcomings:
a. They are only two-dimensional picture of a threedimensional object.
b. Pathological changes in pulp are not visible in radiographs
c. The initial stages of periradicular diseases produce no changes in the radiographs.
d. They do not help in exact interpretation for example radiographic picture of an abscess,
inflammation and granuloma is almost same.
e. Misinterpretation of radiographs can lead to inaccurate diagnosis.
f. Radiographs can misinterpret the anatomical structures like incisive and mental foramen with
periapical lesions
g. To know the exact status of multirooted teeth, multiple radiographs are needed at different angles
which further increase the radiation exposure.

Test cavity
Occasionally, as a last resort, an access cavity is cut into dentine without local anaesthesia as
an additional way of sensitivity testing. This method should be used only when all other test
methods are inconclusive in results.

Selective anaesthesia
Selective anaesthesia can be useful in cases of referred pain to distinguish whether the source
of pain is mandibular or maxillary in origin. It is less useful for distinguishing pain from
adjacent teeth, as the anaesthetic solution may
diffuse laterally.
Electric pulp test. It provides limited but
useful information about the response of the
nerve fibres in the pulp. Many factors affect the
level of response as enamel thickness, area of
probe placement (in the middle third of the

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labial surface), dentin calcification, restorations and patient’s level of anxiety. False positive
and negative results may happen. A newly erupted tooth may give a negative response
whereas a traumatised young tooth may not respond to testing. Multirooted teeth give
inconclusive readings because there are many roots with different degrees of pulp
inflammation in each root canal.

Recent advances in pulp vitality testing

The assessment of pulp vitality is a crucial diagnostic procedure in the practice of dentistry.
Current routine methods rely on stimulation of A-delta nerve fibers and give no direct
indication of blood flow within the pulp. These include thermal stimulation, electrical or
direct dentine stimulation. These testing methods have the potential to produce an unpleasant
and occasionally painful sensation and inaccurate results. In addition, each is a subjective test
that depends on the patient’s perceived response to a stimulus as well as the dentist’s
interpretation of that response. Recent studies have shown that blood circulation and not
innervation is the most accurate determinant in assessing pulp vitality as it provides an
objective differentiation between necrotic and vital pulp tissue.

1. Laser Doppler Flowmetry (LDF)

Pulp is a highly vascular tissue, and cardiac cycle blood flow in the supplying artery is
transmitted as pulsations. These pulsations are apparent on laser Doppler monitor of vital
teeth and are absent in nonvital teeth. The technique depends on Doppler principle in which a
low power light from a monochromatic laser beam of known wavelength along a fiberoptic
cable is directed to the tooth surface, where the light passes along the direction of enamel
prisms and dentinal tubules to the pulp.

2. Pulp oximetry

The pulp oximeter is a non-invasive oxygen saturation monitor in which liquid crystal display
oxygen saturation and pulse rate. Pulp oximetry is especially helpful in cases of traumatic
injury to the teeth during which nerve supply of the pulp may be injured, but the blood supply
stays intact.

3. Dual Wavelength Spectrophotometry

This method measures oxygenation changes in the capillary bed rather than the supply vessels
and hence does not depend on a pulsatile blood flow.

Differential diagnosis

Sometimes clinical signs and symptoms mimic each other they, so have to be enumerated in
different clinical conditions this is known as differential diagnosis. It can include two or more
conditions.