Diagnosis: Case History

• Diagnosis uses scientific knowledge to identify a diseased process, distinguishing it from other diseases

Case History

• Requires information about the patients chief complain, history of present illness, pain levels, vital signs, ad medical history
• Is important to know whether a patient has any general or local conditions that might alter the treatment plan

Chief Complaint

• The patients description of the symptoms causing discomfort, in their own words
• Made without involving diagnosis by the patient or the dentist

History of Present Illness

• Requires asking questions about pain
• Quality: Should be asked if dull, sharp, throbbing, or constant
• Location: Should be asked if localized, diffuse, referred, or radiating
• Duration: Should be asked if constant, intermittent and/or for how long (seconds/minutes/hours)
• Onset: Should be asked if stimulation required, or intermittent/spontaneous
• Initiated: Should be asked if initiated by cold, heat, palpation, or percussion
• Relieved: Should be asked if relieved by cold, heat, medication, or sleep

Pain

• The pain's character is sharp and bright when A(delta) fibers are functioning, indicating acute tissue injury
• Dull, boring, or throbbing pain indicates the C fibers are functioning, indicating severe damage
• The source of pain can be in the tooth or the PDL
• A(delta) fibers in teeth indicate acute, sharp pain
• C fibers in teeth indicate dull pain
• If the PDL is generating the pain, it is sensitive to chewing or percussion
• Pulpal pain cannot be localized because it has no proprioceptive fibers
• Inflammation that extends to periapical tissue makes it easier to localize the pain
• Supine position may increase pain due to increased blood flow to the inflamed pulp
• Primary pain is of dental origin
• Heterotrophic pain is referred pain, such as cardiac pain

Vital Signs

• Consist of temperature, pulse rate, respiratory rate, and blood pressure

Medical History

• Record endocranial disorders like diabetes and hyperthyroidism, cardiac conditions, hypertension, bronchial asthma, allergies, peptic ulcers, bleeding disorders, and infections

Extra-Oral Examination

• Requires looking for facial asymmetry, patient skin for dermal disease, head and neck examination (bimanual examination of masticatory muscles &TMJ), maximum opening of patient, and any detected LNs

Intraoral Examination

• Consists of percussion and pulpation
• Percussion: Tenderness implies inflammation in PNLs which may be caused by occlusion, trauma, sinusitis, or PD diseases
• Pulpation: Sensitivity indicates inflammation in the PDLs surrounding the affected tooth has spread to periosteum surrounding the jaw bone

Mobility

• For the determination of the integrity of the attachment apparatus (cementum, PDL, alveolar bone)
• Grade 1 mobility is less than 1mm lateral
• Grade 2 mobility is 1mm lateral
• Grade 3 mobility is greater than 1mm lateral and vertical

Periodontal Examination

• The determination of pocket depth (PD probe)
• The determination of attachment loss (recession of alveolar bone)

Vitality Test

• Pulp vitality tests are important because they determine both the vitality of a tooth and the status of pulp health
• Objectives include assessing pulpal or periodontal pain, and differentiating periapical pathologies
• Determines the health of pulp based on its qualitative sensory response prior to restorative and endodontic procedures
• Assesses status of pulp as a follow-up after trauma to teeth
• Checks the status of a tooth, especially after a pulp capping or deep restoration
• Used to diagnose oral

Thermal Testing

• Measures the effect of temperature on pulpal inflammation
• Used vitality testers evaluate integrity of Ad fibers by applying stimulus to the outer surface of the tooth surface
• A positive response means functional nerve fibers exist and does not indicate status of blood supply

Cold Test

• Cold causes the contraction of dentinal tubules resulting in outward flow of fluid from tubules and thereby pain
• Differentiates reversible and irreversible pulpitis
• The pain of irreversible pulpitis persists after the stimulus is removed
• The pain of reversible pulpitis disappears after the stimulus is removed
• Can be done by water spray, ice sticks, various compressed gases (ethyle chloride), and CO2 snow

Heat Test

• Applied by: direct warm air to the tooth surface, a heated gutta-percha stick, a device like a hot burnisher or hot compound, warm water from a syringe, frictional heat from a polishing disk, and a laser

Responses to Thermal Stimuli

• Normal response to thermal stimuli has a slight pain that subsides immediately (1-2 sec) after the stimulus is removed
• Reversible pulpitis has a strong pain that subsides immediately (1-2 sec) after the stimulus is removed
• Irreversible pulpitis has moderate to strong pain for several minutes after removal of stimuli
• No response to thermal stimuli has a necrotic pulp, excessive calcification, or immature apex

Electric Pulp Test

• Uses electric excitation to stimulate A(delta) fibers within the pulp
• A +ve response to electric pulp test dose provides no information about the health of the pulp and indicates only the presence of integrated nerve fibers
• Isolate the teeth and explain the procedure to reduce anxiety
• The teeth are isolated to avoid false-positive responses, drying the tooth surface, and applying a rubber dam
• Apply an electrolyte on the tooth e.g. polishing paste or toothpaste, to the tooth surface/electrode
• Avoid contacting the adjacent gingival tissue or metallic restorations to avoid false-positive responses
• Each tooth is tested 2-3 times, and the average reading is noted and control teeth are tested

Disadvantages Of Electric Pulp Tests

• The test does not determinate the vascularity/health of the pulp
• False +ve result includes patient conditions (anxiety) and tooth/saliva condition related to metallic restorations, contact wih saliva and liquefaction necrosi
• False -ve results are the result of premedication/alcohol use, and tooth conditions such as an immature tooth, recent trauma, and the presence of partial necrosis with remining vital pulp
• Avoid use in patients with pace makers

Measuring Pulpal Blood Flow

• Indicates pulpal health, especially with trauma
• If revascularization occurs, no RCT is needed
• If no revascularization occurs, RCT is needed

Laser Doppler Flowmetry

• Depends on the Doppler principle
• A monochromatic laser beam of known wavelength is directed to the tooth surface via a fiber-optic cable
• Light enters the tissue and is scattered and adsorbed by stationary and moving tissues
• Photons that contact with moving red blood cells are scattered and shifted
• Photons that interact with stationary tissues are scattered but not shifted
• Part of light is returned back to photon detector and signal is produced
• Since RBCs represent main moving entity in pulp, Doppler shifted light is inferred as an index of pulpal blood flow

Pulse Oximetry

• A noninvasive oxygen saturation monitor widely used in medical practice
• Records blood oxygen saturation levels during intravenous anesthesia
• The principle is based on the absorption of light by a solute based on its concentration and optical properties at a given wavelength
• The sensor consists of two light emitting diodes: one to transmit red light (wavelength approximately 660 nm), and another to transmit infrared light (wavelength 850 nm)
• This also consists of a photodetector on the opposite side of the vascular bed
• When LED transmits light through vascular bed, different amount of light is absorbed by oxygenated and deoxygenated hemoglobin
• These changes are analyzed in pulse oximeter to evaluate saturation of arterial blood

Special Tests

• Includes crown removal, selective anesthesia test, cavity test, bite test, and transillumination

Crown Removal

• Symptoms of irreversible pulpitis may be present with crowned tooth and pulp vitality test is a part of the tooth assessment with thermal or electric pulp tests
• Removal of crown is done to confirm diagnosis and determine the tooth restorability

Selective Anesthesia Test

• Excludes the source of pain by injecting interligamentary anesthesia
• Injections to the distal sulcus can affect two adjacent teeth, complicating source determination
• Heterotrophic pain is identified if anesthesia relieves the pain

Cavity Test

• Performed on patients where the tooth does not respond to cold stimuli but respond to EPT (false -ve )
• A cavity preparation is done without anesthesia to check the patient discomfort or pain as reaching DEJ or near the pulp
• Restoration needed in vital tooth
• RCT is needed if non-vital

Bite Test

• Identifies a cracked or fractured tooth
• Performed if patient complains of pain on mastication
• A tooth is sensitive to biting if pulpal necrosis has extended to the periodontal ligament space or if a crack is present
• Place hard object on the tooth and ask the patient to bite on the tooth
• Pain present on biting indicates apical periodontitis, and pain present on release of biting force indicates a cracked tooth
• Tooth sloth is another commercially available device for bite test

Transillumination

• Use of fiber-optic light to transilluminate a fracture line to diagnose cracked tooth syndrome

Dyes

• Remove extensive restoration
• Stain fractured teeth with methylene blue
• Dye can be applied to the tooth/ placed in prepared cavity/ given as disclosing tablet to chew
• Dark stain on fracture line detects the fracture

Radiographic Examinations

• Include both Intraoral and Extraoral
• Intra oral radiographs include intraoral periapical, occlusal, and bitewing films
• Extra oral films include panaromic, lateral cephalograms, tomograms, and computed tomography

Radiographs

• Help establish diagnosis
• Determines the prognosis of tooth,
• Discloses the presence and extent of caries
• Check the thickness of periodontal ligament
• Determines any periodontal lesion associated with tooth
• Visualize the number, shape, length, and pattern of the root canals
• Check any obstructions present in the pulp space
• Determine any previous root canal treatment
• Look for presence of any intra-radicular pins or posts
• Assess the quality of previous root canal filling
• Demonstrate any resorption present in the tooth using a radiograph showing obturation
• Demonstrates the presence of calcification in pulp space
• Visualize root end proximal structures
• Determines the working length, length of master gutta-percha cone, and quality of obturation
• Assist in the knowledge of instrumental errors like perforation, ledging, and instrumental separation

Limitations of Intraoral Radiographs

• A 2D image of 3D object
• Are limited determining pulp health
• Include anatomy and superimposition of both tooth and anatomical structure
• Cause giometric distortion in mesiodistal and buccolingual direction fractures
• Small root resorptions are difficult to detect
• Soft tissue injury and early root crack/fractures are difficult to detect
• CBCT helps improve image clarity

Cone-Beam Computed Tomography (CBCT)

• Provides the critical information about the teeth and their surrounding tissues using diagnostic imaging techniques
• Maxillofacial cone-beam computed tomography (CBCT) was introduced in 1996 and provides clinically practical 3D imaging
• Overcomes the shortcomings of conventional radiography by producing 3D images that show accurate anatomy and spatial relationship of the pathosis and anatomical structure
• Clinicians can view slices of the volumetric data in all planes, eliminating anatomical noise
• Provides superior image quality of dental hard tissues
• Provides early detection of resorption and fracture
• Helps to diagnose soft tissue injury
• Can be used to determine the cause of endodontic failure (missed canal, mishaps)
• Helps with treatment plans