3. Endodontic Clinical Examination & Diagnosis Flashcards
What are the different types of clinical tests we can conduct when we carry out an endodontic clinical examination?
- Periapical tests - Percussion, palpation
- Pulp sensitivity (vitality) tests - cold, heat, electrical
- Periodontal examination - Periodontal probing, mobility tests
What are the periapical tests and what are they indicative of?
- A positive percussion test (TTP) indicates inflammation in the periodontal ligament… However, inflammation is not always of pulpal origin so other tests should be carried out
- A positive palpation test (TTPp) indicates inflammation in the periapical tissues into the bone and mucosa in the apical region
What are the pulp sensitivity tests and what are they indicative of?
(Cold Test)
• Done with Endo Ice (-26.2 degree celcius) on a DRY tooth
• Positive test (Short, sharp response) occurs with normal pulp, reversible and irreversible pulpitis. A more intense and prolonged pain is associated with irreversible pulpitis
• Negative tests indicate necrotic pulp
• More effective on anterior teeth than posterior teeth (more insulated)
(Heat Test)
• Done with GP on labial surface, hot water or rotating dry prophy cup. Teeth may be isolated to prevent false-positives
(Electric Pulp Test)
• Stimulates sensory fibres within the pulp, contraindicated in patients with cardiac pacemakers
• Does not measure the degree of disease of pulp
(Test Cavity)
• Direct dentine stimulation by drilling a cavity
• Sudden sharp sensation indicates that the pulp still contains vital tissue
Other tests include:
- Selective anesthesia (when pain cannot be localized to max or mand arch), so a block can be given to isolate either arch
- Transillumination (vital teeth appear bright and clear),
- Wedge or biting test (useful to test for vital pulp)
- Thermocouple (vital teeth have higher surface temperatures)
What are the periodontal tests and what are they indicative of?
(Periodontal Probing)
• Deep isolated and narrow pockets in a may be indicative of a vertical root fracture
(Mobility Tests)
• Teeth with extreme mobility have little periodontal support
• Extensive periapical lesions may alter support significantly
What are the different classifications for pulpal diseases?
Normal pulp, reversible pulpitis, irreversible pulpitis (asymptomatic or symptomatic), pulpal necrosis, previously initiated treatment, previously treated tooth
• RCT is indicated for irreversible pulpitis and pulpal necrosis, it may be indicated for reversible pulpitis
What are the characteristics of normal pulp and reversible pulpitis?
(Normal Pulp) • MILD-MODERATE response to cold test • EPT positive • NTTP • Normal radiographic appearance of PDL space
(Reversible Pulpitis)
• HYPERSENSITIVE to cold test
• EPT positive
• Pain only when stimulus is there, no pain when removed
• Normal radiographic appearance of PDL space
• Could be due to caries, unlined deep restorations or periodontal root planing
What are the characteristics of irreversible pulpitis? How do we further classify irreversible pulpitis?
- Clinically, acutely inflamed pulp is symptomatic, chronically inflamed pulp is asymptomatic
- May be associated with intermittent or continuous episodes of spontaneous pain. May be sharp, dull, localized, or diffuse and may last only minutes or for hours
- Responds to cold test and electric pulp tests. If inflammation is confined to the root canals, response to percussion and palpation tests is normal
There are 2 sub-categories: symptomatic (lingering thermal pain, sponaneous pain, referred pain) and asymptomatic (no clinical symptoms but inflammation still present)
What are the characteristics of pulpal necrosis?
Usually asymptomatic, may be associated with episodes of spontaneous pain or pain to pressure
- No response to pulp tests
- Effects of necrotic pulp are seldom confined within root canals. As a result of spread of inflammatory reactions to periapical tissues, teeth can be sensitive to percussion and palpation (TTP, TTPp)
What are the classifications of periapical diseases based on the AAE2013 Classification? What are their characteristics?
(Normal Apical Tissues)
• Lamina dura, bony area and PDL space normal, NTTP, NTTPp
(Symptomatic Apical Periodontitis)
• Inflammation of apical periodontium that presents with pain to biting and percussion
• May or may not be associated with apical radiolucencies
(Asymptomatic Apical Periodontitis)
• Inflammation and destruction of apical tissues due to pulpal origin, does not present with clinical symptoms
• Appears as an apical radiolucent area
(Acute Apical Abscess)
• Localized destruction of tissue and is a severe inflammatory response to irritants from a necrotic pulp
• Severe discomfort and swelling of rapid onset. Pain to pressure (don’t percuss!)
• Patient may have systemic manifestations of infective process such as high temperature and malaise
• No response to pulp tests
(Chronic Apical Abscess)
Inflammatory response to pulpal infection and necrosis
• Gradual onset, little discomfort with intermittent discharge of
pus through an associated sinus tract. May also drain through the periodontium into the sulcus and mimic a periodontal pocket.
• Radiographically, similar to asymptomatic apical periodontitis
(Condensing Osteitis)
• A very low-grade, subclinical inflammatory response may lead to an increase in bone density rather than resorption. Often confused with enostosis or sclerotic bone which does not require treatment
• Condensing osteitis (focal sclerosing osteomyelitis), a variant of chronic apical periodontitis, represent a diffuse increase in trabecular bone in response to a persistent irritant
• May be asymptomatic or associated with pain and discomfort
• If there is altered or necrotic pulp, RCT is indicated
In pulpal diagnosis, what is the difference between previously initiated treatment and previously treated teeth?
- Previously initiated therapy teeth are teeth that have been treated by partial endodontic therapy (such as pulpotomy and pulpectomies)
- Previously treated teeth are teeth that have not only been treated, but also obturated with rootfilling materials (other than intracanal medicaments)
What are the additional diagnosis that can be used in endodontic diagnosis?
Hyperplastic pulpitis, Canal calcification, Internal resorption
(Hyperplastic Pulpitis)
• A form of irreversible pulpitis, it is result of growth of chronically inflamed young pulp into occlusal surfaces of carious crowns
• Related to the ample vascularity of young pulp tissue
• Usually painless, found during clinical examination as a reddish cauliflower-like outgrowth of connective tissue into carious crowns
• RCT indicated
(Canal Calcification)
• Calcific metamorphosis leads to partial or almost complete radiographic. Could be due to trauma, dental caries, attrition or periodontal disease obliteration of pulp chamber and root canal
• Tooth asymptomatic, usually NTTP, NTTPp
• Tooth colour may become darker yellow
• Tooth may or may not respond to thermal and electric pulp stimuli
(Internal Resorption)
• Must be treated promptly to prevent tooth destruction!
• Inflammation in the pulp may at times cause pulp tissue to transform into highly vascularized granulation tissue with dentinoclastic activity, which resorbs dentinal walls of root canal.
• Presentation is usually asymptomatic
• Both internal and external root resorption may present with a pink spot in the crown
• Appears as a radiolucent lesion with irregular enlargement of the root canal
