Clinical examination and pulp vitality testing procedures. Dental radiology
Healthy pulp Reversible pulpitis Irreversible pulpitis Necrotic pulp Infected pulp
Symptoms which the patient presents to the dentist: Painless - pulpitis is, as a rule, painless; teeth requiring root canal treatment are often detected on routine recall visits Sharp pain to cold which disappears when the stimulus (cold air or drink) is removed, is associated with the pulpodentinal myelinated A-delta neurofibers, the pulp is inflammationfree or reversibly inflamed
Severe pain which lingers – severe pain to hot and sometimes cold which lingers minutes or hours after the stimulus is removed, indicates inflammation Pain to hot relieved by cold – severe inflammation Pain on biting - severe inflammation involving the pulp and periodontium
DIAGNOSTIC TESTS SENSITIVITY TESTS -Electric pulp test -Thermal tests -Test drilling Mechanical tests -Percussion -Palpation Radiographic examination
Electric pulp test(EPT)
Electric pulp tester uses electric current to stimulate the sensory nerves of the dental pulp (fastconducting myelinated fibers-Adelta at the pulpdentin junction)
PROCEDURE The tooth and surrounding teeth are dried. The pulp test probe is placed on the incisal edge or cusp. Contact between the probe and tooth is facilitated by the use of a conducting medium such as toothpaste or fluoride gel. The circuit must be completed with a lip contact. The amount of current is increased slowly, the patient is instructed to indicate if a tingling or heat sensation is felt.
A positive response to the EPT is an indication of vital pulp tissue A negative response indicates total necrosis or localized necrosis The response of young pulps to the EPT is unreliable since the complete developement of the plexus of Raschkow does not occur
Cold test We use frozen sticks of carbon dioxide, cotton pellet sprayed with difluorodichloromethane, ethyl chloride Procedure - dry the tooth and surrounding teeth - the cold object should be placed on the incisal edge or close to a pulphorn for maximal results
A positive response is an indication that pulp is vital, but does not indicate if inflammation is reversible A negative response is highly indicative of necrosis It is the most effective vitality test for immature teeth
Heat test It is difficult to perform since too much heat can in itself cause irreversible harm to the pulp PROCEDURE We use temporary stopping of guttapercha heated over an alcohol flame and is placed on the buccal surface toward the incisal edge DIAGNOSTC INFORMATION A negative response is indicative of necrosis of the pulp
When full coverage restorations are present and other tests are impossible This is the final diagnosis of pulp necrosis A positive response indicates a vital pulp but gives no information about the pathologic involvement of the pulp
Mechanical tests Percussion
indicative of periodontal ligament (PDL) inflammation It is performed with digital pressure,with a handle of a mouth mirror which is used to percuss occlusal,lingual and facial surfaces of the teeth The aim is to determine the presence or absence of inflammation in the apical periodontium A negative percussion test does not rule out the presence of inflammation of periradicular tissues
It is used to detect inflammation in the mucoperiosteum around the root of a tooth It may be possible to detect tenderness,fluctuation,hardness or crepitus before extensive swelling is present The index finger is pressed against the bone through the mucosa
Bitewing radiographs – to detect caries if the pulp is vital A periapical radiographs A panoramic radiographs A occlusal radiograph
A radiograph cannot detect pulpal inflammation directly Caries or defective restorations seen on the radiographs will indicate pulp inflammation The presence of apical radiolucency of endodontic origin may be an indication that necrosis or a necrotic zone is present in the pulp space
TYPES OF INTRAORAL RADIOGRAPHIC FILM AND THEIR PURPOSES Periapical. The periapical film provides information concerning the entire tooth and adjacent tissues.
USES OF THE PANORAMIC RADIOGRAPH a complete survey can be made of the teeth and related structures, some tumors and cysts can be examined and evaluated, the location and position of impacted teeth may be determined, fractures of the lower face may be located, and growth patterns of the jaws can be studied and evaluated.
ADVANTAGES OF THE PANORAMIC RADIOGRAPH the large area of coverage, the bilateral view of anatomy, low patient radiation dose, it can be used on handicapped patients, children, and on those who are unable to open their mouths.
DISADVANTAGES OF THE PANORAMIC RADIOGRAPH The definition of the x-ray is not as sharp as a periapical or a bitewing x-ray. Small caries, periapical disease along with other diseases, and abnormalities that would show up on intraoral x-rays would not be identified on a panoramic view. Other problems would include magnification, distortion, and natural overlapping of some of the teeth.
Bite-Wings X-rays - These type of X-rays are very effective at discovering tooth decay. Similar to periapical X-rays except that only the crowns and part of the roots are seen for 2 or 3 adjacent teeth.
Occlusal X-rays are less common than either Bite-Wing or Panoramic X-rays. These type of X-rays are taken to show the whole bite of the lower and upper jar.