DIAGNOSIS & TREATMENT
PLANNING in
endodontics
BY:
CHAITRA DEVI
Before initiating dental Rx,one must 1st
assemble collective information regarding
the signs,symtoms & history,& then this
information is combined with results from
clinical examination & tests,& this process is
called Diagnosis.
Accurate diagnosis can only result from the
synthesis of scientific knowledge, clinical
experience,intutions & common sense,
therefore diagnosis is both an art & science.
Diagnostician must have thorough
knowledge of the pathosis,R/G & clinical
manifestation,examination procedures & the
Rx modalities.
And above all skills, one must learn to
listen to the pts problem patiently.
 Ingle: Diagnosis is a procedure of accepting pt
recognising that he/ she has a problem,
determining cause of the problem & developing a
Rx plan that will solve this problem.
 Stedman’s medical dictionary :Clinical diagnosis
described as “the determination of the nature of
disease made from a study of the signs &
symptoms of the disease”
Gunnar Bergen Holtz: It’s the art of
distinguishing one disease from the other.
Vimal Sikri: Utilization of scientific
knowledge for identifying a disease process
& to differentiate it from other diseases
 The SOAP format, is best used for patient evaluation
and diagnosis,it designates:
 Subjective: Information obtained from the patient and
family members.
 Objective: Data obtained from observation, physical
examination, or diagnostic test results.
 Assessment/Appraisal:it is the dentist’s diagnosis based
on subjective and objective findings.
 Plan:The planned treatment.
 Its defined as phenomenon or sign of a departure
from the normal & are indicative of illness.
 Classified as:
1.Subjective symptoms :Those experienced &
reported by the pt to the clinician.
2.Objective symptoms: Those ascertained by the
clinician through various tests.
Diagnostic tests are usually assessed in
terms of specificity & sensitivity.
Specificity: Ability of the test or observation
to clearly differentiate one disease from
another.
Sensitivity: Ability of the test or observation
to detect the disease when ever it is truly
present.
 Diagnosis starts the moment the pt enters
the clinic.Pt’s overal assessment,his way of
dressing,gait & general wellbeing should be
noticed at first instance.
Excitement & apprehension on the face of
the pt should also be calculated,& by this
time pt is socially & psychologically assessed.
A. History taking &
B. Clinical tests
o A complete history will not determine the Rx but
may influence modification in endodontic Rx
modalities.
o Good history must record:
1.Bio data
2.Chief complaint
3.History of presenting illness
4.Past dental history
5.Past medical history
1. Name:
 Identification.
 Maintain records.
 Better Communication.
 Psychological benefit
Eg:if there is complete absence of
teeth even at the age of 4-5 yrs
Hereditary ectodermal dysplasia
may be suspected.
Pulp chambers are placed at a
higher level in young permanent
teeth so care to be taken while
working on such teeth.
More the chances of obliterated
root canals in aged teeth.
 3.Sex:
 Incidence of certain disease more in certain sexes
eg:
 Females-iron deficiency anemia,caries,Sjogrens’s
syndrome,torus palatines etc
 Males-Attrition,carious deciduous
teeth,leukoplakia,Ca of buccal mucosa etc.
4.Address:
It is necessary for future correspondence with the
patient ,few diseases have geographic prevalence.
eg: Dental caries and mottled enamel are dependant
on fluoride content of domestic water,caries more
common in modern industrialized area while pdl
diseases are more common in rural areas.
5.Occupation:
Hepatitis B-dentists,
surgens,blood bank personnel.
Gingival staining – strange dark
staining of marginal gingiva
seen in persons working with
lead,bismuth,cadmium.
Attrition –seen in patients
exposed to atmosphere of
abrasive dusts & cannot avoid
getting the material into his
mouth.
Habitual opening of pins may
result in notching of incisal
edges as seen with
carpenters,shoemakers or
tailors.
6.Religion &
7.Marietal status are the other things to be
included in the biodata.
Is the reason for which the pt comes to the
doctor or the reason for seeking treatment.It
should be recorded in patients own words &
attention should be given 1st to It.If few
complaints start simultaneously it should be
recorded in order of severity.
The development of pt’s history is a interview
process during which the dentist attempts to
evaluate pt’s symtoms accurately,completely
& objectively avoiding temptation to make a
premature diagnosis.
Pain is frequently main
component of chief complaint &
therefore questions should be
asked regarding
1.Onset of pain
2.Kind/type of pain
3.Duration of pain
4.Aggrivating &relieving factors,
5.Whether it is referred to
another site or not
 Onset of pain: sudden or gradual
 Type of pain:
Sharp,piercing & lancinating – Due to the excitation
of A-δ fibers of the pulp,this pain reflects on the
reversible state of the pulpitis.
Dull,boaring,& extruciating pain due to exicitation &
slower rate of transmission of C-fibers of pulp.This
pain reflects on the irreversible state of pulpitis.
 Duration of pain:
If pulpal pain remits relatively “quickly”within few
sec after stimulus removed,it is pressumed to be
suffering from reversible pulpitis.
While if pulpal pain “lingers” for 30 sec or more after
stimulus is removed,indicative of irreversible
pulpitis.
 Localization of the pain:
Pain is localized when pt can point to spot a specific
tooth or site with assurance & the speed when asked to
do so.
 Referred pain :
Perception of pain in one part of body that is distant
from the actual source of pain.
 Pain of non-odontogenic origin can refer pain to the
teeth,teeth may also refer pain to other teeth as well
as to other anatomic areas of head & neck.
 Referred pain from tooth is usually provoked by an
intense stimulation from C-fibers in pulp,which
causes an intense slow,dull throbbing pain.
 Referred pain always radiates to the ipsilateral side
of tooth involved.
 Ant teeth seldom refers pain to other teeth or to opp
arch,whereas post teeth may refer pain to the
opposite arch or to the preauricular area,but seldom
to ant teeth.
Highlights pt’s attitude
towards dental Rx,what sort of
dental Rx done before &
complications if any occurred.
Also the allergy to dental
ointments,pastes,
mouthwashes,LA should be
noted.
This gives information about any
significant or serious illness a pt
may have or had as a child or
adult.
Specific questions regarding
heart,liver,kidney or lung
diseases,diabetes,radiation,
allergic rxns,infectious diseases,
cancer chemotherapy &
bleeding disease should be
asked.
 Any pt with the history of rheumatic fever has the
potential of suffering sub acute bacterial
endocarditis after any bacteremia,because every
dental procedure has the potential to cause some
degree of bacteremia,definite measures should be
taken to avoid the possibility of SABE.
 Often pt with previous h/o coronary occlusion is
receiving anticoagulants.
 Non-surgical endodontic treatment-no alteration in
administration of anticoagulants.
 If surgery becomes mandatory-pts physician to be
contacted.
It was suggested to avoid L.A with
epinephrine while Rx pts.with
HTN,unfortunately L.A without
epinephrine has less profound effect &
shorter duration of action than those
containing it.
Pain felt by pt may produce much more
endogenous epinephrine than that
included in anaesthetic soln,for this reason
epinephrine content of 1:1,00,000 is
considered apt.
 No more than 3 carpules of anaesthetic soln should be
used at single appointment.
 In severe haemophilics bleeding from pulp & periapical
tissue can be persistent & troublesome.If the tooth to
Rx is necrotic no L.A is needed.
 Topical application of 10% cocain is recommended for
vital tooth extirpation.
 If conservative Rx is not feasible without L.A
intraligamentary inj is unlikely to cause any bleeding.Care to
be taken while placing matrix bands to avoid any trauma.
 Healing is retarded & it should be considered while
evaluating pt with DM.
 Periodic post operative check up R/G’s to be taken as R/L are
slower to fill with bone than in normal pt’s.As these pt’s are
more prone to inf antibiotics to be employed in presence of
inf or if surgical procedure is to be carried out.
 L.A with epinephrine is not recommended in DM pts as
it inc the blood sugar level by stimulating the
sympathetic nervous system,& also because these pts
suffer from capillary ischemia due to atherosclerosis,inc
epi causes tissue sloughs after surgical
procedure(levonordefrin-vc sub).
 Special attention to be given to pt’s with
MI,asthma,epilepsy,allergies,TB,HIV.
Family history:
Certain conditions are likely to be
inherited like DM,hemophilia,HTN etc
& should be explored by asking series
of questions.
.
Personal history:
Should include asking about
oral hygiene habits,pressure
habits like thumb
sucking,finger sucking,tongue
thrusting,mouth
breathing,bruxism or
bruxomania
 They are useful as an indicators of systemic disease,in
addition this information is also essential as a standard
reference should the syncope or other untoward
medical complication arises during patient treatment.
 Normal respiratory rate during rest-14-16 breath/min.
 Tachypnea(rapid breathing): >20breaths/minute.
 Body temp in dental pt is checked in case systemic
illness or systemic response to secondary dental
infection(bacteremia).
 Recent drinking of cold or hot drinks or mouth
breathing in warm or cold air alters the oral temp.
severe oral infection may alters the local oral
temp,even in the absence of fever.
 Normal body temp- Oral(sublingual)-98.6°F/37.0°C
- Aural-99.6°F/37.7°C
-Axillary-97.6°F/36.3°C
 Pulse rate:
60-100beats min-normal
<60beats/min-Bradycardia
>100beats/min-Tachycardia.
 B.P:
normal:120/80mm Hg for the person under the age of
60yrs;130/90mm Hg over the age of 60yrs.
B.P should be controlled before starting any surgical Rx
& when diastolic B.P is 100mm Hg or above no pt with
or without dental emergency should be Rx unless its
got under control.
TMJ
-Lymph nodes
-Swelling
-Facial asymmetry
-Extra oral sinus tract.
1.Visual examination:
A thorough visual, tactile examination of hard and
soft tissues relies on three “3Cs” – i.e Contour, Colour
and Consistency”.
In soft tissues such as gingiva any deviation from
healthy,pink colour is readily recognized when
inflammation is present.
While in case of hard tissue normal appearing tooth
has life like Translucency.
Discolorations could be due to
necrotic pulp,old amalgum resto,Rc
filling materials &
medicaments,tetracycline staining
etc.
A change in gingival contour
occurs when there is infm & swelling.
Change in crown contor can occur due to
#,wear faecets ,
restorations,developmental defects etc.
A change in consistency from normal
healthy firm gingiva to soft,fluctuant or
spongy one indicates pathological
condition.
Consistency of hard tisue relates to the
presence of caries,internal & external
resorption.
 Visual examination should be carried out under good
light under dry condition,if not
 In the presence of saliva & packed food may mask the
presence of sinus tracts,interproximal caries etc.
 Loss of translucency,slight discoloration,cracks may
also go unnoticed.
Tenderness on percussion does’nt
indicate that tooth is vital or nonvital,rather an indication of
inflammation in periodontal
ligament.
Inflammation may be secondary to
Physical trauma,occ
prematurities,periodontal diseases
or extention of pulpal disease into
PDL space.
 Tooth is percussed in vertical & horizontal direction
initially with low intensity by index finger,if the pt
cannot detect any significant difference b/w any of the
tooth& then test is repeated with back end of mouth
mirror with inc intensity.
 The contralateral tooth should be 1st tested as a
control,as well as several other teeth that are certian
to respond normally & then the tooth of interest.
 Although it is a simple test if it is used alone may be
misleading,to eliminate this bias on the part of the
pt,1 must change the sequence of the teeth percussed
on successive tests.
 A dull note on percussion signifies abcess formation
& sharp note merely means inflammation.
 It must be noted that a tooth must not be percussed
beyond the pts tolerance.
Manual digital palpation of the soft tissues
around or adjacent to the tooth in question
can be extremely helpful
1.Locating the swelling,
2.To know if tissue is fluctuant & enlarged,
3.The presence ,intensity & location of pain.
4.Presence of bony crepitus.
 While palpating the lymph nodes in the presence of
acute infection care has to be taken to avoid the
possible spread of inf through the lymphatic vessels.
 Clinician should always bilaterally palpate both the
areas in the question & the contralateral side.
B/L palpation is imp b’coz:
 1.subtle changes in anatomy often cannot be detected
unless both ipsilateral & contralateral areas are
evaluated simultaneously.
 2.swelling on the ipsilateral side may not be significant
until the contralateral side is palpated at the same time.
 3.better assessment of consistency of either neoplastic
or inflammatory swelling with b/l palpation.
 Absence of discomfort during palpation does,nt mean
that disease is not present or that the tissue is healthy
eg;painless ameloblastoma.
 Conversely the presence of discomfort does’nt mean
that the disease is present.
 It is not an indication of pulp vitality,rather an
indication of compromise to periodontal attachment
apparatus,as a result of VRF,periodontal disease,rapid
orthodontic movt,occlusal trauma or an extension of
pulpal disease.
 Often mobility reverses to normal after the initiating
factors are repaired or eliminated.
Mobility can be detected by using:
 Back ends of 2 mouth mirrors,1 placed buccally & other
placed lingually is used to record the degree of tooth
movt.
 Periotest:
Periotest projects a rod against the
tooth using magnetic impulse at a certain
speed.
The apparatus measures deceleration
time needed before the rod comes to
stand still.
This is transformed in a arbitrary unit,
which reflects if the tooth is having
pathological mobility by displaying values.
Values should be below plus 7,min with
the most rigid being -8.
Millers index:
 Class1: 1st distinguishable sign of movt greater than
normal.
 Class2:movt of tooth as much as 1mm in any
direction.
 Class3:movt of tooth more than 1mm in any
direction &/or depression or rotation of the tooth.
 This test consists of moving the tooth verticaly in the
socket.
 Performed with fingers or with instruments,when
depressibility exists the chances of retaining the
tooth ranges from poor to hopeless.
 Measurement of periodontal pocket depth is an
indication of depth of gingival sulcus which
corresponds to the distance b/w height of the free
gingival margin & height of the attachment
apparatus below.
Deep pockets indicates
horizontal or vertical bone
loss.
Caliberated periodontal
probe is STEPPED around the
long axis of
tooth,progressing in mm
increments to record the
pocket depth.
 Deep periodontal probing is generally considered to
be periodontal etiology & is typically more
generalized in other areas of the mouth.
 While isolated areas of vertical bone loss may be of
an endodontic etiology,specifically from non-vital
tooth who’s infection has extended from periapex to
gingival sulcus .
 Furcation bone loss can be secondary to
periodontal or pulpal disease.
Glickman’s classification:
 Grade1: incipient lesion when pocket is suprabony
involving soft tissue & there is slight bone loss.
 Grade2:Bone is destroyed on 1 or more aspects of
the Furcation but a probe can only penetrate
partially into Furcation.
Grade3: Intraradicular bone
is completely absent but
tissue covers the furcation.
Grade4: A through &
through Furcation defect.
 R/g’s provide pertinent info about:
 Presence of caries that may involve or threaten to
involve pulp.
 Root anatomy-no.course,shape,length,& width of
root canal.
 Presence of calcified material in pulpchamber or root
canals.
 Thickening of PDL
 Nature & extent of periapical & alveolar bone
destruction,
 Anatomic landmarks asso. with roots:
Maxillary sinus,
Mandibular canal,
Mental foramen .
 # of root are difficult to detect on R/g,
 Vertical root # can only be diagnosed in advance
cases of root separation as compared to horizontal
#’s.
 Horizontal # must be diff from linear pattern of bone
trabeculae.
It is done with fiberoptic light directed
through crown of the teeth.
By this method,a pulpless tooth that is
not noticeably discolored may show a
gross difference in translucency when
shadow produced on mirror is compared
to that of adjacent tooth.
Transillumination can detect
interproximal caries & #’s mainly vertical.
 During this test operating light is switched off &
fiberoptic light is moved closer to the neck of the
tooth.
 Light doesn’t pass through #,thus the part of tooth
beyond # remains dark.
 Most reliable results are obtained if restorations are
removed before examination.
 Thermal tests
1.Heat test
2.Cold test
 Electric pulp testing
 Mechanical testing.
 Probing exposed dentin in a cavity or cervically at the
neck of the tooth often results in sensitive reaction in
the vital tooth
 Mech stimulation is generally considered to have high
sensitivity & specificity.
Heat → Vasodilation → ↑sed IPP → PAIN
 Application of heat to normal teeth gives delayed
response because it takes time for the specific pulpal
temp. to be reached.
 In an inflammed pulp ↑sed IPP already exists therefore
immediate painful response is seen.
Heat test can be performed using:
1. Heated gutta percha stick,
2. Hot compound,
3. Hot burnisher/inst that can deliver controlled temp to
teeth.
4. Frictional heat produced by rotating polishing rubber
disc against tooth surface.
5. Hot water.
The preferred temp for heat test-65.5°C(150°F).
 Teeth in the quadrant to be dried,isolated & lubricated with
coco butter or petroleum jelly to prevent hot GP stick from
sticking on to teeth.
 Heated GP stick is placed at the jnc of cervical & middle 3rd
of facial surface of the tooth to elicit any response.
 The most effective thermal test for any tooth including a
tooth with porcelain or metal full coverage involves
isolating the tooth & bathing it in warm water delivered in a
syringe.
Sys B allows to set a specific temp,
after tooth surface has been
lubricated, a hot pulp test tip can
be attached to the handle of Sys B
& the temperature set at 150°C,the
tip is then placed on the tooth
surface,& pt response is evaluated.
 Brannstrom attributes the pain from cold is due to
Hydrodynamic mechanism

Cold → Contraction of fluid → rapid outward flow of
fluid in the dentinal tubules → deformation of
peripheral Aδ nerve membranes → PAIN
 Response to cold in a normal tooth is immediate
A stream of cold air: Directed
against tooth,if no response then
other materials is to be tried.
Ice: Inexpensive & readily
available,but as ice melts & can
spread to either soft tissues or
adjacent teeth false positive result
can occur.
Ethyl chloride spray :it evaporates rapidly
absorbing the heat and thus cooling the
tooth.
Dichloro-difluromethane:
1,1,1,2 Tetrafluro ethane: It’s a new
formulation of Endo ice having zero
ozone depletion potential & is
environmentally safe having temp of
-26.2°C.
It was shown when that when endo
ice was used with #2cotton
pellet(larger) significantly lower
intrapulpal press was achieved
when compared to smaller #4
cotton pellet.
CO2 snow or Dry ice: Is found to be
very reliable in eliciting a positive
response if vital pulp tissue is present in
the tooth,in teeth with full coverage
restoration & even in immature teeth
B’coz of its extremely low temp of
- 78°C.
Dry ice sticks are prepared by
delivering CO2 gas into specially
designed plastic cylinder.
Thermal testing may give false positive results since
tests are solely based on status of nerve supply & not
on blood supply of the teeth.
Reason for false positive results are:
1.Excess calcification,
2.Immature apex,
3.Recent trauma,
4.Pt premedicated with analgesics,narcotics,alcohol or
tranquilizers
Response to EPT does’nt reflect the
histological health or disease status
of the pulp rather denotes that only
some viable nerve fibers are
present in the pulp & are capable of
responding.
Thus the results obtained from EPT
should be compared with cold test
or test cavity.
 Pt does’nt generally don’t feel a true “electric
stimulation” but feel “tingling”/pain sensation
,b’coz A-delta fibers transmit only pain sensation to
CNS & not electric,thermal,touch or proprioceptive
sensation.
 If complete coverage crown or extensive restoration
is present BRIDGING tech.can be employed to
deliver electric current to exposed natural tooth
structure.
1.
2.
3.
4.
5.
6.
7.
8.
Thickness of enamel,
Dentin calcification,
Interfering restorative material,
Cross sectional area of probe tip.
Teeth with pulp protecting base & sedative
medicine,
Traumatized teeth/recently erupted teeth with
incomplete root formation,
Pt’s level of anxiety.
Probe placement on tooth.
 1.When electrodes contact gingiva,
 2.Anxious pt’s,
 3.Failure to dry & isolate the teeth,
 4.Multirooted teeth,when pulp may be vital in 1 or
more rootcanals & necrosed in another,
 5.Liquifaction necrosis,
 6.Electrodes in contact with a restoration conducting
the stimulus to adj teeth.
1. Pt.heavily premedicated
2. Recently traumatized tooth,
3. Excessively calcified canals
4. Presence of pulp protection bases under the
restorations.
5. Partially necrosed pulp,
6. pt. with high pain threshold
7. Dead batteries or forgetting to turn on the pulp
tester.
 Describe the procedure to the pt.
 Isolate the area of teeth to be tested,
 Fnct of EPT,
 Electrolyte applied on electrode & placed on Occ-bucc or
inc-lab surface of dried enamel,
 Pt’s cheek is retracted away from the electrode with free
hands which will complete electric circuite,
 Rheostat is slowly turned to introduce a minimal
current 1st then current slowly inc,
 Pt is asked to indicate when the sensation occurs,
 Results recorded acc to the numerical scale on pulp
tester.
 Analytic technology pulp tester,
 Digilog pulp tester (battery operated),
 Trilite ,
 Parkel : pulp tester ,(Battery – operated)
 Neotest ADP (automatic digital pulp tester).
 Green wood pulp tester,
 Dentometer ,
 Digipex 2,
In pt’s with cardiac pace maker,as it could potentially
interfere with its function.
This test is restricted to pt who
are in pain at the time of when
usual tests have failed to enable
one to id the tooth.
Objective is to anaesthetize a
single tooth at a time until the
pain disappears & is localized to
a specific tooth.
 Infiltration/intraligamentary inj.-post teeth in the
area suspected of being the cause of pain.
 If pain persists even after its has been anaesthetized
next tooth mesial to it is inj.& continued until pain
disappears.
 Pain in maxillary/mandibular teeth?-inf alveolar
nerve block given
 Cessation of pain indicates inv of mandibular teeth
& localization of specific tooth –intraligamentary inj.
 This test is obviously the last resort & has an adv
over the test cavity,during which iatrogenic damage
is possible.
 Involves the slow removal of the tooth str to
determine pulp vitality.
 Test is performed by drilling through DEJ of
unanaesthetized tooth with round bur & slow speed
without coolant.
 If pulp-vital ,pt will experience a quick sharp pain
at/ shortly beyond DEJ.
 Sedative cement is then placed in the prepared
cavity & search for the cause of pain is continued.
 If no pain/sensitivity is recorded,cavity prep is
continued until pulpchamber is reached & routine
endodontic Rx is performed.
 This test to be carried out as a last resort as it causes
iatrogenic damage.
Bite test is indicative when pt
complains of pain on biting &
also is not able to localize it.
This test performed with :
1.Cotton applicator
2.Toothpicks,
3.Orange woodsticks,
4.Rubber polishing wheels,
5.Tooth slooth,
6.Frac Finder.
Tooth may be sensitive on biting due to:
 Periradicular periodontits,
 Incompletely fractured tooth.
 If PP,pt will respond with pain to percussion & bite
tests regardless of where the pressure is applied to
the coronal part of the tooth.
 # tooth will elicit pain only when percussion or the
bite test is applied in certain direction.
 Small cupped out areas of the inst is placed in
contact with cusp to be tested.
 Pt is asked to apply bite press with opp teeth to the
flat surface on the opp side of the device until full
closure is achieved.
 The press should be applied for few sec,&pain
elicted during press phase /upon quick release is
noted.
 Common finding in # tooth or cracked tooth is the
presence of pain upon release of biting pressure.
Gutta perch point tracing: GP point
is passed through the sinus/fistulous
tract & R/G is taken.
This helps in localizing endodontic
lesion to specific tooth,& also helps
to differentiate b/w periodontal or
endodontic lesion.
This test is done to ID & locate vertical #.
Dyes used are:
1-2%methylene blue,
Food colouring agents,
2% iodine.
Methylene blue dye is painted on tooth
surface with cotton applicator & excess is
wiped off with 70% isoprophyl alcohol.Dye
will indicate the possible location of crack.
LDF was 1st into in 1970s to
measure the blood flow in retina.
In dentistry it is used to assess the
blood flow of pulpal
microvasculature.
LDF uses a beam of infrared(780820 nm) or near infrared (632.8 nm)
directed through the crown &
pulpchamber.
As light enters tissue,it is scattered
by the stationary tissue cells &
moving blood cells.
 Photons that hit the stationary cells are scattered
but frequency is not shifted,but,on hitting a moving
RBC frequency is shifted acc to doppler principle.
 LDF has 2 systems:
1.Closed system &
2.Open system
 Equipment-Periflux PF2 with helium-neon laser light
at 632nm.
 As light hits various components of the tissue it is
partially absorbed & partially back scattered.
 Back scattered light is processed & an output signal
is produced that is read on the digital board.
 Uses LA VITAL inst. in combination with laser
diode emitting light at 750nm.
 This inst uses a rigid probe that is hand held on
buccal surface of tooth during measurement .
 Adv of LDF :
1.Non-invasive,simple & provides continuous or near
continuous record.
 Dis adv:
1. Too expensive.
2.The sensor should be maintained motionless and in
constant contact with the tooth for accurate
readings.
 The laser beam must interact with moving cells
with in the pulpal vasculature
Non-invasive method to
determine the pulpal blood flow.
It measures the O2 conc in blood
& pulse rate
Principle :
2 wavelength of light transmitted
by photoelectric diode detect
oxygenated & deoxygenated
hemoglobin as they pass through
a body part receptor
 Diff b/w the light emitted & light received are
calculated by a microprocessor to calculate the pulse
rate & O2 conc in the blood.
 Saturated O2 is 1st measured on the index finger,
 After isolation of teeth,oximetre probe is placed on
the facial surface of crown so that light could travel
through the center of the tooth.
 Values recorded after monitoring each tooth for 30
sec.
 Successful in 70% clinical trials.
 Useful in impact injuries.
 Signal infiltration is introduced which helps to
reproduce pulp pulse reading easily.
 Smaller and cheaper commercial oximeters are now
available.
 Back ground absorption associated with venous blood
and tissue constituents which should be differentiated.
 The oxygen saturation values are lower than the
readings from the patients fingers.
 In addition to absorption, refraction and reflection also
occur as in penumbra effect which is seen in patients
with strong tissue pulsations where some of the light
reaches the photo detector diode without passing
through the tissue bed
 Studies reported that pulpal circulation was much more
efficient than in supporting tissues in maintaining the
temp of the crown in vitro.
 This indicated that measurement of crown surface
temp may determine whether vital or necrotic tissue
fills up the pulp chamber.
 The different methods tried were;
1.Cholesteric compounds,
2.Thermistors,
3.Electronic thermography,
4.Hughes Probeye 4300 thermal video system-was
sensitive enough to measure temp diff of 0.1°C
 DWLS is a method independent of a pulsatile
circulation.
 This method measures oxygenation changes in the
capillary bed rather than in the supply vessels and
hence does not depend on a pulsatile blood flow. Pulse
oximetry is a method based on DWLS.
 Detects the presence or absence of oxygenated blood
at 760 and 850nm.
 Adv
Uses visible light that is filtered and guided to the tooth
by fibreoptics thus does not require additional eye
protection.
The instrument is small, portable and relatively
inexpensive.
 Pain induced by pulsed Nd YAG laser was reported to
be mild & tolerable compared with pain induced by
conventional EPT.
 When normal pulp was stimulated by pulsed Nd YAG at
20W & 20 pulses per sec at a distance of app.10nm from
tooth surface,pain is produced within 20-30sec after
LASER stimulation is stopped.
 In case of acute pulpitis pain is induced immediately
after LASER application & continues for more than
30sec after stopping LASER stimulation.
 DD b/w Acute suppurative & Acute serous pulpitis can
be obtained by combining the measurements of
electric current resistence of caries & pain duration
induced by LASER stimulation.
 Here the image formation is achieved by
photoelectrostatic process & not by photochemical
process as in conventional R/G.
 X-ray image is recorded on a photoconductive selenium
plate rather than X-ray film.
 Before use,selenium plate is given a uniform
electrostatic charge placed in a light proof plastic
casette,positioned in mouth & exposed to x-ray.
 Processed image is transferred onto clear adhesive
tape & fixed onto an opaque plastic base.
 Resultant image may be viewed either as a photograph
with reflected light or as a R/G with transmitted light
from a view box.
 Edge enhancement,
 Inheritently wide latitude & better resolution,
 Less radiation exposure,
 No necessity of wet processing, no dark room
needed
& no processing soln & replenisher needed.
 Images have less granularity,
 Plates may be reconditioned, recharged,& used
repeatedly.
 This tech relies on conversion of serial R/g’s into
digital images.serially obtained digital images can
then be supermposed & resultant composite viewed
on a video screen.
 Change in the density & volume of the bone can be
detected as lighter areas(bone gain) & darker areas
(bone loss)
 Quantitative changes in comparison with the
baseline images can be detected using an algorithm
for grey scale levels,which is accomplished with
computer-assisted subtraction R/g.
 This tech requires a parallelization tech to obtain a
standardized geometry & accurate superimposible
R/g.
 R/g’s taken with identical exposure geometry can be
then scanned using microphotometer that
determines a gray scale values for each picture point.
 After superimposition of 2 subsequent R/g,this
tech can show difference in relative densities.
 It can detect a change in bone mass of as little as 5%
as compared to 30-60% loss of bone mass required
for conventional R/g .
 Demerit:
Need to be close to identical projection alignment
during exposure of sequential R/g’s,which makes this
method very impractical in clinical settings.
 Dev by Dr.Francis Mouyen,RVG provides an
instantaneous image on a videomonitor,while
reducing radiation exposure by 80%.
3 components:
1.Radio component-consists of
hypersensitive intraoral sensor & a
conventional X-ray unit.
2.Visio part-video monitor &
display processing unit.
3.Graphy part-high resolution
video printer.
 Adv:
1.Eliminates the hazards of X-ray film development,
2.Low radiation dose,
3.Significant reduction in exposure time,
4.Instantaneous image display,
5.Can display multiple images,
6.Manipulation of image is possible,
7.Capability of teletransmission
 Demerit:
1.Expensive
2.Sensor is not flexible.
 Consists of X-ray tube attached to an array of
detectors to produce sectional image usually in axial
plane.
 Objects to be visualized is divided into series of
sections or slices & each section is scanned several
times & from many different angles.
 Since resolution is high contrast,this tech can demo
small differences in tissue densities.
 Adv:
1.Hard & soft tissue images is got,
2.Demo small differences in soft tissue density,
3.Eliminates superimposition of structures,
4.Sagital & coronal reconstruction can be obtained,
5.3D images got using relevant software.
 Disadv:
1.Not readily available,
2 expensive,
3.Relatively high dose of radiation,
 Used to determining buccolingual extent of internal
resorption lesion.
 Procedure may be an adjunct in selected cases to
determine whether RCT for Rx of internal resorption
followed by restoration of tooth is likely to sucessful.
 TACT imaging was statistically superior to
conventional radiograph in detecting resorptive
defects.
 Ingle’s Endodontics6- Ingle Bakland & Baumgartner
 Endodontic therapy-Franklin s.wein
 Endodontic practice-11ed- Grossman
 Pathways of the pulp-9th ed-Cohen
 Clinical periodontology 10th ed-Carrenza
 Endodontics -3rd ed- Stock, Walker.&Gulibivala
 Text book of operative dentistry-vimal sikri
 Text book of operative dentistry-summit
Thank you