Dental Lateral Canal Diagnosis

Pulpal Disease Diagnosis

• Lateral canals are portals of entry for toxins, and pulpal degeneration can occur if not diagnosed correctly.
• Thermal and electric pulp tests must be performed along with periodontal examination to distinguish between disease of pulpal and periodontal origin.

Thermal Test Techniques

• Heat test can be performed using different techniques such as:
  • Hot water
  • Hot burnisher
  • Hot gutta-percha
  • Hot compound
  • Polishing of crown with a rubber cup
• Cold test involves isolating the quadrant with the tooth to be tested and using:
  • Cold water
  • Cold air from a 3-way syringe directed against the crown of previously dried tooth
  • Ethyl chloride spray
  • Ice stick
  • CO2 snow

Electric Pulp Testing (EPT)

• The test should be first described to the patient, and teeth to be tested should be isolated with cotton rolls, saliva ejector, and air dried.
• The EPT tester should be checked for proper functioning, and an electrolyte (toothpaste) should be applied to the tooth surface.
• Avoid contact of the electrolyte or electrode with any restorations or the adjacent gingival tissue as this could lead to a false response.

Advantages of EPT

• Intensity of stimulus is comfortable to patients.
• Digital display of many EPT testers provides instant, easy, and reliable information.
• In some EPT testers, a red indicator light flashes on and off when maximum stimulus is reached.
• Gives a quantitative reading and can be compared with the normal reading of control tooth.

Anesthetic Test

• Restricted to patients who are in pain at the time of the test and when the usual tests have failed to help identify or localize the offending tooth.
• The objective is to anesthetize a single tooth at a time until the pain disappears and is localized to a specific tooth.
• If the source of pain cannot be differentiated (i.e., maxillary/mandibular), then a mandibular block is implemented.
• Further localization of the affected tooth is done by an intraligament injection.

Transillumination Test

• Light from a fiberoptic is applied from the buccal surface to illuminate the tooth to detect fractured lines when present.
• From the contact area to detect contact caries.

Biting Test

• Placing the pointed end on each cusp and then having the patient bite and release.
• A normal, healthy tooth will have no pain.
• An orangewood stick is placed on the occlusal/incisal aspect (on each cusp in case of posteriors) of the tooth, and the patient is asked to bite.

Staining

• Remove the filling from the suspected tooth and place 2% Iodine (or other stain) in the cavity preparation.
• The iodine stains the:
  • Fracture line dark.
  • Canal orifice.

Guttapercha Point Tracing

• Can localize the endodontic lesion to the specific tooth.
• Aids in the differential diagnosis between a periodontal and an endodontic lesion.
• Placing a guttapercha point through the sinus/fistula tract and taking a radiograph.

Radiographs Importance

• Provides information on the extent of caries into the pulp.
• Number of root canals and accessories.
• Course and shape of the canals.
• Length of the root.
• Calcifications.
• Resorptions.
• PDL status.

Diagnosis

• Is a process of determining the nature of a disease.
• It is very important for proper treatment.
• Differential diagnosis: is the process of differentiating between similar diseases.
• Sequential agreement is very important for correct differential diagnosis:
  • Proper knowledge of the disease.
  • Skill and art on how to apply proper diagnostic methods.

Clinical Examination

• Extra oral examination:
  • Facial asymmetry.
  • Localized swellings.
  • Changes in color, bruises/ scars.
  • Lymphadenopathy (groups of lymph nodes).
• Visual and tactile inspection:
  • Soft tissue:
    • Color.
    • Contour.
    • Consistency.
  • Hard tissue:
    • Color.
    • Contour.

Medical Conditions Requiring Modification of Treatment and Consultation

• Cardiovascular:
  • High & moderate risk of Endocarditis.
  • Pathologic heart Murmurs.
  • Hypertension.
  • Unstable angina.
  • Recent myocardial infarction (6 months).
  • Arrythmias.
  • Poorly managed congestive heart failure.
• Pulmonary: COPD, Asthma, Tuberculosis.
• GIT & Renal: End stage renal disease, Hemodialysis, Viral hepatitis (A,B,C,E), Alcoholic liver disease, Peptic ulcer disease, Endocrine & Hematologic: STDs: HIV & AIDS, Diabetes mellitus, Adrenal insufficiency, Pregnancy, Bleeding disorders, Cancer & leukemia, Osteoarthritis, rheumatoid arthritis, SLE.

Limitations of Radiographs

• 2D image of a 3D object.
• State of pulpal health cannot be ascertained.
• P/A pathology is evident only after much destruction (33%).
• Early vertical root fracture cannot be diagnosed.
• Bony trabeculae misinterpreted for horizontal root #.
• Extend of caries is usually less than the actual extent as is true for P/A pathology.

Anatomic Structure Can Mimic P.A. Pathology

• Canal seems to disappear due to narrowing of canal space or overlapping of the roots on the radiograph.

Other Radiographic Methods

• Xeroradiography.
• Radiovisiography (RVG).
• Cone beam computerized tomography (CBCT).
• Magnetic Resonance Imaging (MRI).
• Ultrasound imaging.

CBCT

• Basic 3 sections.
• Check the cervical cross-sectional shape.

Trauma and Habits

• Trauma is a common cause of pulp disease in children, resulting from violent blows to the tooth during fights, sports, or household accidents.
• Habits such as opening hard objects with teeth, compulsive bruxism, nail biting, and thread biting can also lead to pulp disease.

Dental Procedures

• Certain dental procedures can injure the pulp, including crown preparation, over-cutting with dull burs, and reduced cooling system of turbines.
• Removing dentin for a crown preparation, curing materials needed for provisionalization, and microleakage under a temporary crown can contribute to possible pre-existing pulpitis.

Pathologic Wear

• Attrition is natural tooth-to-tooth friction that occurs when you clench or grind your teeth, often involuntarily during sleep.
• Abrasion is physical wear and tear of the tooth surface that happens with faulty brushing or hard toothbrushes, fingernails, and chewing tobacco.
• Abfraction is the pathological loss of tooth substance caused by biomechanical loading forces, resulting in flexure and failure of enamel and dentin at a location away from the loading.
• Erosion occurs chemically when acidic content hits the tooth surface, such as with certain medications, highly acidic foods, and frequent vomiting.

Cracked Tooth Syndrome

• Incomplete fracture through the body of the tooth can be due to excessive masticatory forces, causing symptoms ranging from mild pain to severe pain.
• The pulp of the tooth may become necrotic in severe cases.
• Patients may feel pain when biting on a cotton or rubber wheel, and radiological manifestations may include a J-shaped lesion in the late stage.

Thermal Injuries

• Thermal injuries can occur due to cavity preparation, including:
  • Deeper cavity preparation
  • High-speed engines
  • Poor coolant system
  • Extensive cavity
  • Excessive cutting of dentin
  • Dull burs
  • High pressure with cutting

Polishing Injuries

• Polishing with dry powders can lead to temperature rise and heat conduction by restoration.
• Heat conduction can occur through very deep metallic restorations close to the pulp without any intermediate cement base.

Electrical Injuries

• Galvanic current from dissimilar metal fillings can cause pulp disease.

Chemical Causes

• Pulpal inflammation can occur due to:
  • Citrus ingestion
  • Acid etchants used to expose dentin
  • Dehydrating chemicals for sterilizing/drying
  • Gastrointestinal problems that produce repeated exposure of teeth to gastric acids

Bacterial Causes

• Bacterial invasion can occur through:
  • Direct invasion through dentin
  • Invasion through open blood vessels or lymphatics associated with periodontal disease
  • Invasion through blood (anachoretic effect) during infectious diseases or transient bacteremia

Idiopathic Causes

• Aging can cause pulp disease, including:
  • Atrophy of the pulp
  • Decrease in the number and size of cells
  • Increase in collagen fiber content
• Internal resorption can occur due to:
  • Trauma
  • Caries
  • Ortho treatment
  • Infection/pulpitis
  • Extreme heat

Internal Resorption

• Internal resorption is a localized internal dentin destruction due to odontoclastic activity.
• Clinical appearance includes a pink spot on the crown.
• Treatment involves endodontic treatment to arrest the progression of the resorption.

External Resorption

• External resorption occurs when the resorptive tissue is supplied by blood vessels coming through the apex.
• Treatment involves removal of the cause, and in cases where it is accessible, RCT and composite restoration.
• In cases where it is non-accessible, surgical access and correction by MTA or BIODENTINE are necessary.

Pulpitis

• Pulpitis is inflammation of the pulp, and can be classified as:
  • Reversible pulpitis (acute or chronic)
  • Irreversible pulpitis (acute or chronic)
  • Pulp degeneration (calcific or atrophic)
  • Pulp necrosis

Reversible Pulpitis

• Reversible pulpitis is a mild to moderate inflammatory condition that can return to its normal position after removal of stimuli.
• Characteristics include:
  • Sharp pain of short duration
  • Pain subsides after stimulus is removed
  • The affected tooth responds to cold
  • Tooth responds to electric pulp testing at very low levels of current than control tooth

This quiz assesses knowledge on diagnosing pulpal degeneration and distinguishing between pulpal and periodontal disease through thermal and electric pulp tests, periodontal examination, and lateral canal analysis.