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
 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.
 4

Diagnostic Workflow

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

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.
 History of present illness

• Severity and Urgency of the problem

Site of pain Mode of onset Types of pain

Nature of pain Progression of pain Duration of pain

Radiation of pain Aggravating Factors Relieving Factors

S.O.C.R.A.T.E.S

History taking and clinical examination in dentistry. Charu M Marya, (2014)

 Dental History
Attitude towards previous dental treatment

Previous restorative, periodontic,

Frequency of past visits
endodontic or oral surgical treatments

Fluoride History Reasons for loss of teeth

Frequency of Dental Prophylaxis

History taking and clinical examination in dentistry. Charu M Marya, (2014)

 Medical History
• Identification of any condition that may complicate or
contraindicate the proposed dental treatment

Communicable Diseases

Allergies from certain drugs

Systemic diseases

Drug History

History taking and clinical examination in dentistry. Charu M Marya, (2014)

• Obtaining a medical history is an information
gathering process for assessing a patient’s
health status. The medical history comprises a
systematic review of the patient’s chief or
primary complaint, a detailed history related
to this complaint, information about past and
present medical conditions, pertinent social
and family histories, and a review of
symptoms by organ system
 Personal Dental History
Oral Habits Oral Hygiene Habits Adverse Habits

Diet History

History taking and clinical examination in dentistry. Charu M Marya, (2014)

• A habit can be defined as the tendency toward an act that has become a
repeated performance, relatively fixed, consistent and easy to perform by an
individual (Boucher OC).

• Thumb Sucking – Callus on thumb / Flared Proclined Anteriors / Diastemmas /

Retroclined Mandibular Anteriors – Psychological Approach / Reminder
Therapy / Mechanotherapy

• Bruxism - It is defined as the clenching or grinding of teeth when not masticating

or swallowing (Poselt and Wolff) – Psychological and emotional stress /
Magnesium Deficiency / Allergies / Occupational Factors – Psychological
Counselling / Hypnosis / Occlusal adjustments to eliminate prematurities / Night
Guards

• Oral hygiene habits -

 Clinical Examination

Visual Inspection Auscultation

Palpation Percussion

Aspiration Olfaction

History taking and clinical examination in dentistry. Charu M Marya, (2014)

• The history and clinical examination are designed to put the dentist in a position to make a
provisional diagnosis, or a differential diagnosis

• Visual Inspection : Standardized observation of the head and neck region to ensure the
completeness and accuracy of the examination. The face is observed bilaterally for any
asymmetry or changes

• Palpation : It is used to determine the size, texture, consistency, symmetry, temperature of soft
tissues, swellings or lymphnodes. Palpation may be done either by hand or by both hands
(bimanual palpation)

• Percussion : It is performed by gentle tapping over the area with fingers or an instrument to
determine the relative consistency of the structure with its surroundings. Patient
• may even feel pain while the procedure, providing valuable information about the area
percussed.

Auscultation : It is the listening to sounds. It is performed by the unaided ear or by the assistance
of a stethoscope. A dentist should evaluate the sounds of crepitus or popping like in case of TMJ,
blood pressure sounds

Aspiration : It is the removal of whole or a part of fluid from a body cavity. The area aspirated is
usually a soft tissue or a bony lesion having a fluid-filled cavity

• Olfaction : Some odors can be associated with conditions of the patient such as smoking
habits, poor oral hygiene, sinusitis, metabolic disorders, gastrointestinal disorders
 Extra-Oral Examination
Lymph Nodes
Face

TMJ
Lips

Skin

History taking and clinical examination in dentistry. Charu M Marya, (2014)

• The dentist should be looking for any abnormalities in the colour, texture and appearance
of the skin, such as presence of any Rash, Sore, Ulcer. Any change in colour such as it
signifies Anemia and Jaundice. Texture of the skin should be checked, skin becomes dry and
inelastic in dehydration and becomes greasy in acromegaly. Also look for petechial
hemorrhages (eg : in blood dyscrasias)

• Head should be examined for its appearance and circumference – Hydrocephalus

• Shape of head – Mesocephalic / brachycephalic / dolicocephalic / Hyperbrachycephalic
• Paget’s disease, scleroderma and Bells palsy can manifest with charactestic ‘facies’ which
can be easily identified.

• Face Symmetry - Diagnosis of the symmetry of patient’s face is important so as to

determine the disproportions of face in transverse and vertical planes. Gross asymmetries
in the face is a result of Congenital Defects / Hemifacial Hypertrophy or Hypotrophy
• Shapes of face : Mesoproscopic / Leptoproscopic / Hyperleptoproscopic / Europroscopic /
Hypereuroproscopic
• Facial Profiles : Straight Profile / Convex Profile / Concave Profile

• Nose : Nasal obstructions could lead to mouth breathing habit / Epistaxis in severe cases like cerebral
hemorrhage

• Labial Mucosa : Lip is gently turned out. Should appear wet and shiny.

• Lip : Note the lip color, texture, and any surface abnormalities as well as angular or vertical fissures,
sores, ulcers, nodules, plaques, scars and swellings. Notice the vermillion border and the presence of
Fordyce’s granules
• Lip competence : competent / incompetent / pseudo-competent / everted

• Lymph nodes : neck lymph nodes are better palpated while standing at the back of the patient, if the
lymph nodes are palpable, a dentist should look for – location, number, size, tenderness, consistency
and mobility.

• TMJ :
 Intra-Oral Examination
Lips / Labial Mucosa Buccal Mucosa

Tongue Tonsils & Oro-Pharynx Hard Tissue Examination

History taking and clinical examination in dentistry. Charu M Marya, (2014)

 History & Record

Symptoms

Subjective Objective
• Symptoms - phenomena or signs of a departure from the normal state and are
indicative of illness.

• Subjective symptoms are symptoms that are

Subjective –
experienced and reported by the patient, but cannot be
objectively measured or observed by a healthcare
provider. These symptoms are often subjective because
they are based on the patient's own perceptions and
experiences, and may vary from person to person.

• The completed medical form concerning the patient’s past medical and dental
history consists of subjective symptoms. Included in this category is the
patient’s reason for seeing the dentist or chief complaint. Generally, a chief
complaint relates to pain, swelling, lack of function, or esthetics.

• Objective – Objective symptoms are physical signs or symptoms that can be

observed or measured by a healthcare provider. These symptoms are objective
because they are based on objective measures or observations, and can be
objectively confirmed or evaluated.
 History & Record

Diagnosis

Provisional Diagnosis Diagnosis by Exclusion

Differential Diagnosis

Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
• Differential - This technique
distinguishes one disease from
several other similar disorders by
identifying their differences

• Exclusion - Eliminates all possible

diseases under consideration until
one remaining disease correctly
explains the patient’s symptoms.
 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.
 All About Pain
KIND LOCATION DURATION

• Sharp, Piercing, Lancinating • Localized Pain • Short and Specific to stimuli

(reversible pulpitis) (Reversible Pulpitis) (Reversible Pulpitis)

• Persistent & Lingering pain

(Irreversible Pulpitis)

• Dull, Boring or Gnawing • Spontaneous Pain

(irreversible pulpitis) • Diffused Pain (Irreversible Pulpitis)
(Irreversible Pulpitis)
• Nocturnal / Postural Pain
(Irreversible Pulpitis)

Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
 The Diagnostic Aid Pool
CONVENTIONAL RADIOGRAPHIC

1) Visual & Tactile Inspection 1) Intraoral periapical radiographs

2) Percussion 2) Bitewing Radiographs
3) Palpation 3) Digital Radiography
4) Mobility & Depressibility 4) Cone Beam Computed Tomography
5) Bite Test

ASSESSMENT OF PULP VITALITY

NEURAL SENSIBILITY TESTS PULP VASCULARITY TESTS

1) Thermal Tests 1) Pulse Oximetry
1.1) Heat Testing 2) LASER Doppler flowmetry
1.2) Cold Testing 3) Recent Technologies
2) Electric Pulp Test 3.1) Dual Wave Spectrophotometry
3) Anesthetic Test 3.2) Thermography
4) Test Cavity 3.3) Crown Surface Temperature
3.4) Transmitted Light Photoplethysmography

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

Normal Vital Tooth Non-Vital Tooth

Discolouration due to Crack developing on marginal

old amalgam filling ridge & extending into the
pulp chamber

Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
• A dentist should carefully examine the appearance
of teeth, if there is loss of the natural life-like
translucency and sparkle of the tooth, that might be
indicative of pulpal inflammation, degeneration and
necrosis

• Not all discoloured teeth need endodontic

treatment, it may be due to old amalgam fillings,
root canal filling materials or medicaments such as
tetracycline or minocycline
 Normal Contour, Colour & Inflamed gingiva losing its
Consistency of Gingiva 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.
• In soft tissues, such as gingiva, deviation from the healthy
pink color is readily recognized when inflammation is
present

• change in contour occurs with swelling, and the

consistency of soft, fluctuant, or spongy tissue differs
from that of normal, healthy, firm tissue and is indicative
of a pathologic condition

• The periodontium should be examined under good

lighting under dry conditions, for example if a clinician
might miss detecting a sinus tract if it is covered by saliva
or an interproximal cavity if it is filled with food debris.
 Tactile Examination

Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)
• No. 23 / No. 17 and DG-16 explorers used for detection of caries, open
restorative margins, fractures, loose cusps and fracture lines

• Softness is checked at the base of caries to ascertain the presence of an

active or inactive carious lesion

• Often it is possible to feel the presence of a deep fracture line

and follow it vertically along the proximal surface. Obviously,
the more apical the fracture is felt, the more likely there is
pulpal involvement

• We should be careful during tactile examination to avoid

iatrogenic errors, as one might transfer micro-organisms from
one tooth to another while probing the carious lesion
 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

Submental Lymph Nodes Infected

Submandibular Lymph Nodes Infected

Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
• The palpation test is performed by the clinician using his or her
fingertips

• We usually ascertain whether the tissue is fluctuant & enlarged enough

for incision drainage
• The presence, intensity and location of pain
• And lastly the presence and location of adenopathy

• Palapation tendereness decreases with the increase in the cortical bone

or external oblique ridge such as in mandibular molars

• Swellings are to be examined for their temperature, mobility,

tenderness, fluctuant or not, rigidity, transluscency
 Percussion Testing

Apical Pathology Periodontal Pathology

Symptomatic of

Standardization of force

Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)
• Pain on percussion is not crucial to a pulpal diagnosis but is symptomatic
of three other conditions.
• It may be a sequela of trauma which applies virtually to all anterior teeth
• It may be the result of periapical inflammation due to either
a necrotic or an acutely inflamed pulp. Depending on the
acuteness or chronicity of the underlying pathosis, both
the percussion tenderness and concomitant palpation
tenderness can be either mild or extremely acute.
• Third, tenderness to percussion may be a symptom of
occlusal trauma, most often the result of nocturnal
clenching or bruxing

• Percussion testing is ideally done by tapping the

contralateral teeth around the tooth in question.
• Every effort should be made to standardize the degree of
force used although the force cannot be measured
 Percussion Testing
Sensitive to
Bruxism percussion in one
direction

Sensitive to
Periodontitis percussion
in any
direction

Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)
• Following percussion of the teeth along the
vertical axis of the tooth, the teeth are also
tapped with the mirror handle on the inner slopes
of the cusps (on posterior teeth) and at 90
degrees to the long axis of the tooth

• A traumatically injured tooth and a tooth with

periapical periodontitis will be sensitive in any
direction
• Teeth that have become sensitive to percussion
from bruxism may be sensitive to percussion in
only one direction.
 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

Wooden Stick

“Tooth Slooth” (Professional

Results
Inc., Laguna Niguel, CA, USA)
Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)
• Patients who complain of having difficulty to chew from one side of the
mouth
• Percussion tests are not useful in such cases as they are not specific to the
cusps the patient might be having a problem with
• A bite pressure test is performed by having the patient bite
directly onto a device or material placed between the teeth
• This test is done tooth by tooth and on the opposite side so
the patient has an idea of what is normal and what is
expected
• Wooden handle of a cotton applicator, cotton end of the
cotton applicator or an orangewood stick can be used
• The commercially available “Tooth Slooth” can be used as
well
 Mobility Testing
The mobility test is used to evaluate the integrity of the
attachment apparatus surrounding the tooth
A result of

Periodontally Sound

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

• Mobility in a tooth is indicative of either an advanced periodontal

disease, periapical abscess and occasionally occlusal trauma

• The test consists of moving a tooth laterally in its socket by using the
fingers or, preferably, the handles of two operative instruments

• The objective of this test is to determine whether the tooth is firmly or

loosely attached to its alveolus. The amount of movement is indicative of
the condition of the periodontium; the greater the movement, the
poorer the periodontal status.

• Similarly, the test for depressibility consists of moving a tooth vertically

in its socket. This test may be done with the fingers or with an
instrument.
 Millers Mobility Tooth Index

First Degree Mobility Second Degree Mobility Third Degree Mobility

Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
• 1 – First distinguishable sign of movement greater
than normal
• 2 – Horizontal tooth movement within a range of
1mm
• 3 - Horizontal tooth movement greater
than 1 mm or when the tooth can be
depressed
 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.
 Radiographic Methods

 Intra-Oral Periapical Radiographs

 Bitewing Radiographs
 Digital Subtraction Radiography
 Cone Beam Computed Tomography
 Intra-Oral Periapical Radiographs

• Intra Oral Peri Apical Radiographs –

Diagnosis of caries since times
immemorial

• It should not be the expectation Proximal caries in maxillary

that every pulpally involved tooth second premolar

will have radiographic signs of

pathosis.

Problem Solving in Endodontics, 5th Edition, by James L. Gutmann and Paul Lovdahl (2011)
• Radiographs are indispensable diagnostic and prognostic
aids in endodontics and are one of the most reliable
methods of monitoring endodontic treatment
• It is impossible to determine the condition of the pulp
itself on a radiograph.
• The only observable changes are loss of hard tissue,
usually bone surrounding the apex.
• Periapical pathosis is, in turn, a consequence of pulpal
necrosis and extreme pulpal inflammation
• Inflammation and infection of the periapical tissues are
the result of necrotic tissue products and bacteria that
emanate from the apical foramen and sometimes from
lateral canals that can be present at a separate location
on the root
 Radiographic Applications in Endodontics

According to Walton & Gomez :

Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
• According to Walton and Gomez, radiographs have many
applications in endodontics, such as
- Help in the diagnosis of hard tissue alterations in the
teeth and periapical structures
• - Determine the number, location, shape, size, and
direction of roots and root canals
- Assess anatomy, size, and alterations in the pulp
chamber
- Estimate and confirm the length of canals
- Aid in locating a pulp space markedly calcified and/or
receded
- Confirm the position and adaptation of master cones
- Evaluating presence of root fractures
 Bitewing Radiographs

Interproximal Caries Crowns and alveolar crest of maxillary and

mandibular teeth

DIAGNOSTIC OBJECTIVES

White, Stuart C., and Michael A. Pharoah. Oral Radiology: Principles and Interpretation. St. Louis, MO:
 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.
Digital Subtraction Radiography
 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:
• A divergent X-ray source, collimated as a cone or
more commonly, as a pyramid, is directed through
the region of interest (ROI) within the maxillofacial
region
• And the residual attenuated photons strike the
detector on the opposite side.
• During rotation of the gantry, multiple sequential
planar projections images are captured

• Scan time ranges from 5 to 30 seconds

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
 Cone Beam Computed Tomography
Assessment of Dental Trauma and Extent of Lesions

Horizontal root fractures usually affect maxillary central incisors and are typically
traumatic in origin, associated with accidents, sports injuries or fights

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
Cone Beam Computed Tomography
 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:
• Endodontic complications : such as overextended
root canal obturation material, separated endodontic
instruments, and localization of perforations
• Presurgical treatment planning to localize
root apex/apices and to evaluate the
proximity to adjacent anatomical
structures
 Neural Sensibility Tests

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

Positive
Flow of dentinal fluid towards pulp Not as accurate as Cold Test
Pressure

65.5 Celsius Gutta Percha Stick / Ball Burnisher /

C-fibres stimulated
5 seconds Prophy Cup without water

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.
• Heat test is a thermal diagnostic aid in dentistry, it consists of using either a heated
gutta percha stick, a heated ball burnisher or a silicon polishing cup mounted on a
contra-angle handpiece without the use of water.

• Heat causes indirect stimulation of A-Delta fibers which causes expansion of the
dentinal tubular fluid, creating a positive pressure resulting in the movement of
dentinal fluid towards the pulp, This movement physically affects the
odontoblastic processes of odontoblasts that stimulate the A-
delta fibers. This phenomenon is called mechanotransduction.

• The negative pressure created by Heat test stimulates less

nerve fibers than what the positive pressure created by cold
test does, as demonstrated by Vongsavan and Mathews. Hence
the superiority of cold test is more than the heat test.

• One thing that the heat test has which cold test doesn’t is the
stimulation of slow conducting C-fibers. Due to which some
consider heat test to be the ultimate test
•
• Studies show that a temperature of 65.5 degrees Celsius is enough to elicit a response
in the pulp.
 Cold Test

Ice Sticks / Ethyl Chloride / DichloroDifluoroMethane / Dry Ice Isolate the tooth

Positive Pressure Cotton Pellet to be used Endo Frost (-50*C)

TFE (-26*C) 15 seconds

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.
• Cold test is a thermal diagnostic aid in dentistry, it consists of using
either
• Heat causes indirect stimulation of A-Delta fibers which causes
expansion of the dentinal tubular fluid, creating a positive pressure
resulting in the movement of dentinal fluid towards the pulp, This
movement physically affects the odontoblastic processes
of odontoblasts that stimulate the A-delta fibers. This
phenomenon is called mechanotransduction.

• The negative pressure created by Heat test stimulates

less nerve fibers than what the positive pressure created
by cold test does, as demonstrated by Vongsavan and
Mathews. Hence the superiority of cold test is more than
the heat test.
 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.
 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.
 Pulp Vascularity Tests

Dental Pulse Oximetry

Laser Doppler Flowmetry

Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
 Dental Pulse Oximetry

Non-invasive method to measure

oxygen saturation levels of blood

Works on the principle of light

absorption by blood and analyzing NOT COMMERCIALIZED YET
the relationship between the
pulsatile changes of absorption
 Principle of Dental Pulse Oximetry
Units consists of POS + Photodetector + POM
POS
Red + Infrared light 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
Photodetector

The relationship between the pulsatile change in

the absorption of red light and the pulsatile
change in the absorption of infrared light is
POM 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.
 Laser Doppler Flowmetry
Non Invasive Method Real-Time

Measures rate of blood flow

Continuous
in a microvasculature

Readings largely dependent on the linearity of the

COSTLY flowmeter output to the changes in the RBC Flux

Red He-Ne gas lasers & Near Depth penetration of N.I.R Diode lasers is
Infrared Diode Lasers used 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.
 Principle of Laser Doppler Flowmetry

Laser light transmitted through Light enters RBC’s which leads

fiberoptic source and placed on to shift in frequency of
tooth surface scattered light

The proportion of frequency

Detection of blood movement
shift is detected by a
through pulp space done
photodetector

Parameswaran, A. "Grossman's endodontic practice - 14th edition." Endodontology, vol. 33, no. 2, Apr.
 Recent Diagnostic Aids in Endodontics

 Computed Infrared Thermographic Imaging

 Tuned Aperture Computed Tomography

 Fiber-optic Trans-illumination Method

 Thermistor

 Orascope
 Computed Infrared Thermographic Imaging

Measures the surface Temperature can be measured

temperature of tooth accurately from a distance

Camera is capable of detecting temperature

changes as small as 0.1 degree Celsius

Accurately indicates
Real Time Data Non - Invasive
pulpal blood flow

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.
 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

Excellent for vertical root fracture detection

Detected 36% more extra Mesio-Buccal canals

in Maxillary first molars and 80% more Mesio-
lingual canals in mandibular molars

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.
 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
• As dentists were using Radiographs for diagnosing and visualizing the internal
tooth structure, peri-apical area and surrounding bone for caries detection and
anomalies, it had its own disadvantages pertaining to the dose of ionizing
radiation the patient and the dentist receives throughout the process, even at low
levels

• These concerns invited alternative methods, there has been a considerable

interest in employing non-ionizing, visible light radiation to detect caries

• Carious lesions have a lowered index of light transmission, which simply means
caries will appear as darkend areas when the tooth surface is illuminated with a
specific light source.

• FOTI is a device that delivers illumination from a 150 watt halogen lamp via fiber
optics to the tooth surface
• The light propagates from the fiber illuminator across the tooth tissue to non-
illuminated surfaces
• The carious lesions appear as dark shadows due to the lowered refractive index of
carious tooth structure than the sound tooth structure
• Calculus appears as dark areas
• Transluscent restorative materials can be easily distinguished from the tooth
 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.
The applications of FOTI are numerous

1) It can be used to visualize the a supplemental diagnostic aid

for anterior and posterior interproximal caries and
occlusal caries diagnosis
2) detection of calculus
3) evaluation of stained margins of composite resins and
of cusp fractures and cracked teeth
4) an exploration tool to illuminate endodontic access
and root canal orifices within the pulp chamber of teeth
during endodontic treatment
5) evaluation of all-ceramic restorations to rule out any
fractures before cementation
6) clinical evaluation of fracture and craze lines in
existing all-ceramic restorations and natural teeth
 Thermistor
Small Thermometer – can detect Even a drop of saliva can
minute temperature changes change the thermal readings

Vital teeth rewarm to normal temperature after Thermistor measures this

intentional cooling below room temperature change in temperature

Non vital teeth cannot regain the

same temperature once cooled

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.
 Orascope

Flexible fiberoptic intracanal visualization device Not commercialized yet

Has a 0.8mm tip No Radiation

1:1 image to sensor ratio

Working portion 15mm in length

Useful in identifying intracanal anatomy

Abnormalities in root canals

Root canal calcifications

Pandey D, Chaturvedi P, Shuklai V. Recent Diagnostic Aids in Endodontics.

 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.
Bibliography
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Marmaneu-Menero A, Iranzo-Cortés JE, Almerich-Torres T, Ortolá-Síscar JC, Montiel-Company JM, Almerich-Silla JM. Diagnostic Validity of Digital Imaging Fiber-Optic Transillumination (DIFOTI) and
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