Patient Evaluation, Diagnosis and Treatment Planning in

Operative DentistryDr. Hakan Çolak

DDS. PhD

Ishık University School of DentistryDepartment of Restorative Dentistry

INTRODUCTION• To provide best treatment and patient satisfaction,

thorough clinical history, examination and diagnostic aids are required. Since dental problems are not alike in two patients, thorough examination, evaluation and diagnosis of an individual patient guides the effective treatment plan

• Diagnosis is defined as utilization of scientific knowledge for identifying a diseased process and to differentiate it from other disease process.

• In other words, literal meaning of diagnosis is determination and judgment of variations from the normal

Outline

• Patient Evaulation– Case History– Chief Complaint– History of Patient İllness– Past Dental History– Medical History

• Examination and Diagnosis– Clinical Examination– Periodontal Evaulation– Evaulation of Carious

Lesions

– Evaulation of Existing Restorations

– Radiograph– Study Casts– Laboratory Investigations– Occlusion Examination– Pulp Vitality Tests

• Recent Advances in Pulp Vitality Testing

• Treatment Planning• Treatment Record

PATIENT EVALUATION

PATIENT EVALUATION

• The diagnostic process actually consists of four steps:

1. First step: Assemble all the available facts gathered from chief complaints, medical and dental history, diagnostic tests and investigations.

2. Second step: Analyze and interpret the assembled clues to reach the tentative or provisional diagnosis

3. Third step: Make differential diagnosis of all possible diseases which are consistent with signs, symptoms

and test results gathered

4. Fourth step: Select the closest, possible choice

• The importance of making an accurate diagnosis cannot be overlooked. Many a times even after applying all the knowledge, experience and diagnostic tests, a satisfactory explanation for patient’s symptoms is not determined.

• In many cases, nonodontogenic etiology is also seen as a source of chief complaint. To avoid irrelevant information and to prevent errors of omission in clinical tests, the clinician should establish a routine for examination, consisting of chief complaint, past medical and dental history and any other relevant information in the form of case history

• In many cases, nonodontogenic etiology is also seen as a source of chief complaint.

• To avoid irrelevant information and to prevent errors of omission in clinical tests, the clinician should establish a routine for examination, consisting of chief complaint, past medical and dental history and any other relevant information in the form of case history

Case History

• Purpose– discover whether patient has any general or local

condition that might alter the normal course of treatment

– Comprehensive medical and previous dental history should be recorded. In addition, a description of the patient’s symptoms in his or her own words should be noted.

Chief Complaint

• Importance– overall treatment plan revolves around the chief

complaint– It consists of information which promoted patient

to visit a clinician. – Symptoms are phenomenon or signs of deviation

from normal and are indicative of illness. The form of notation should be in patient’s own words.

History of Present Illness

History of Present Illness

• More descriptive analysis about this initial information– signs and symptoms – duration, intensity of pain, – relieving and exaggerating ( triggering )factors

Examples of type of the questions

• How long have you had the pain?• Do you know which tooth it is?• What initiates pain?• How would you describe the pain?

– Quality—Dull, Sharp, throbbing, constant– Location—Localized, diffuse, referred, radiating– Duration—Seconds, minutes, hours, constant– Onset—Stimulation required, intermittent,

spontaneous– Initiated—Cold, heat, palpation, percussion– Relieved—Cold, heat, any medications, sleep

History of present illness should indicate severity

and urgency of the problem.

History of present illness should indicate severity

and urgency of the problem.

• If a chief complaint is toothache but symptoms are too vague (uncertain) to

establish a diagnosis, – analgesics should be prescribed to help the

patient in tolerating the pain until the toothache localizes.

• A history of pain which persists without exacerbation may indicate problem of

nonodontogenic origins.

Toothache

• Pulpal pain can be sharp piercing if A-delta fibers are stimulated.

• Dull, boring or throbbing pain occurs if there is stimulation of C-fibers.

Pulpal Pain

Pain from periodontal ligament

• The tooth will be sensitive to; – percussion– chewing – palpation.

Marking the intensity of pain

Patient is asked to mark the imaginary ruler with grading ranging from 0 to 10 0-No pain 10-Most painful

• Mild to moderate pain can be of pulpal or periodontal origin but acute pain is commonly a reliable sign that pain is of pulpal origin.

• Localization of pain also tells origin of pain since pulp does not contain proprioceptive fibers; it is difficult for patient to localize the pain unless it reaches the periodontal ligament

Past Dental History

• This helps to know any previous dental experience and past restorations.

Medical History

• There are no medical conditions which specifically contraindicate operative treatment, but there are several which require special care.

Allergies or Medication

• If the patient is allergic to local anesthetic during dental treatment, he/she may go in the

state of anaphylactic shock. • Allergic reactions may occur in the form of itching, rashes, swellings, gingivitis, ulcers, etc.

Allergies or Medication

. Effect of various medicaments• altering salivary flow • interfere with the metabolism of the other drugs • may cause the pigmentation of oral soft tissues

Communicable Diseases

• Immunocompromised patients – more prone to suffer from various bacterial,

fungal and viral infections due to suppression of immuneresponse

Systemic Diseases

Physiological Changes Associated with Aging

• Physiological changes associated with aging should be examined properly and should not be confused with the pathological changes. Changes in oral cavity occurring due to aging are as follows:– Attrition, abrasion and wear of proximal surfaces

– Extrinsic staining– Edematous gingivae– Diminished salivary flow– Gingival recession

Erosion in a 32-year-old male patient with high cola beverage consumption particularly at times of dehydration from BMX bicycle competitions. The incisal edges of the maxillary anterior teeth were thinned and chipped, whilst cervical lesions affected the canines and premolars (a). (From Young &

Messer, 2002, with permission of Dentil Pty Ltd.) Palatally, extensive degradation affected all anteriors and first premolars (b)

EXAMINATION AND DIAGNOSIS

• Clinical examination: It includes both extraoral and intraoral examination

• Intraoral examination: It includes the examination of soft and hard tissue.

Clinical Examination

• Following sequence is followed during clinical examinations– Inspection– Palpation– Percussion– Auscultation– Exploration.

Inspection

• Patient should be observed for – unusual gait and habits (may suggest underlying

systemic disease, drug or alcohol abuse)– localized swelling, – presence of bruises, – abrasions, scars – signs of trauma

Inspection

• Degree of mouth opening– it should be at least two fingers

Inspection

• During intraoral examination, look at the following structures systematically– The buccal, labial and alveolar mucosa– The hard and soft palate– The floor of the mouth and tongue– The retromolar region– The posterior pharyngeal wall and facial pillars– The salivary gland and orifices.

Inspection (general dental state)• Oral hygiene status• Amount and quality of restorative work• Prevalence of caries• Missing tooth• Presence of soft or hard swelling• Periodontal status• Presence of any sinus tracts• Discolored teeth• Tooth wear and facets

Palpation

• Local rise in temperature• Tenderness• Extent of lesion• Induration• Fixation to underlying tissues

Percussion

• Percussion gives information about the periodontal status of the tooth

• Percussion of tooth indicates– inflammation in periodontal ligament which could

be due to • Trauma• Sinusitis • PDL disease

Percussion

• Percussion can be carried out by gentle tapping with gloved finger

• blunt handle of mouth mirror

Each tooth should be percussed on all the surfaces of tooth until the patient is able to localize the tooth with pain. Degree of response to percussion is directly proportional to degree of inflammation.

Each tooth should be percussed on all the surfaces of tooth until the patient is able to localize the tooth with pain. Degree of response to percussion is directly proportional to degree of inflammation.

Periodontal Evaluation

• Periodontal examination shows change in – color– contour– form– density– level of attachment – bleeding tendency

Periodontal Evaluation

• The depth of gingival sulcus is determined by systemic probing using a periodontal probe.

• A sulcus depth greater than 3 mm and the sites that bleed upon probing should be recorded in the patient’s chart

• The presence of pocket may indicate periodontal disease

Periodontal Evaluation

• The mobility of a tooth is tested by placing a finger or blunt end of the instrument on either side of the crown and pushing it and assessing any movement with other finger

Periodontal Evaluation

• Grading of mobility– Slight (normal)– Moderate mobility within a range of 1 mm.– Extensive movement (more than 1 mm) in

mesiodistal or lateral direction combined with vertical displacement in alveolus

Evaluation of Carious Lesions

• Dental caries is diagnosed by the following– Visual changes in tooth surface– Tactile sensation while using explorer– Radiography

• Definite radiolucency indicating a break in the continuity of enamel is carious enamel

– Transillumination

Evaluation of Existing Restorations

• Proximal overhangs– Proximal restoration is evaluated by moving the

explorer back and forth across it. If the explorer stops at the junction and then moves onto the restoration, an overhang is present. This should be corrected, as it can result in the inflammation of the adjacent soft tissues.

• Marginal gap or ditching: It is the deterioration of the restoration-tooth interface on occlusal surfaces as a result of wear or fracture. Shallow ditching, less than 0.5 mm deep usually requires patchwork repair. If ditch is too deep, restoration should be completely replaced

• Amalgam blues: These are the discolored areas seen through the enamel in teeth. The bluish hue results either from the leaching of corrosion products of amalgam into dentinal tubules or from the color of underlying amalgam as seen through translucent enamel

• Voids: These also occur at the margins of amalgam restorations. If the void is at least 0.3 mm deep and is located in the gingival one-third of the tooth crown, then the restoration should be replaced

• Fracture line: A fracture line that occurs in the isthmus region generally indicates fractured restoration which needs replacement

• Recurrent caries at the margin of the restoration also indicate repair or replacement of the restoration

Radiograph

• Most important tools in making a diagnosis.• Without radiograph, case selection,

diagnosis and treatment would be impossible as it helps in examination of oral structure that would otherwise be unseen by naked eye.

• Radiographs help to diagnose tooth related problems like – Caries– Fractures– root canal treatment – any previous restorations– abnormal appearance of pulpal or periradicular

tissues– periodontal diseases and the general bone pattern

Periapical lesions of endodontic origin have following characteristic features

• Loss of lamina dura in the apical region• Etiology of pulpal necrosis is generally

apparent• Radiolucency remains at the apex even if

radiograph is taken by changing the angle.

Indications of dental radiographs

• Deep carious lesion• Large restoration• History of pain• History of trauma• History of root canal

treatment• History of periodontal

therapy• Family history of dental

anomalies

• Impacted teeth• Mobility of teeth• Swelling in relation to teeth• Presence of sinus/fistula• Unusual tooth morphology• Missing teeth with

unknown reasons• Growth abnormalities.

Disadvantages of radiographs

• Radiograph gives two dimensional picture of a three dimensional object

• Caries is always more extensive clinically when compared to radiograph

Pulpal Diagnosis

Pulpal Innervation

Healthy (Normal) Pulp

• pulp is vital, without inflammation.• asymptomatic, react to vitality tests such as

heat, carbon dioxide(CO2) snow, ice and/or electric pulp tester (EPT)

• Once the pulp gets ‘older’ it forms increasing amount of secondary dentin in the pulp chamber such that its reaction to thermal test might be diminished, but even in those cases a healthy pulp should predictably react to EPT

Reversible Pulpitis

• This diagnosis implies that the pulp is vital, but has some local area/s of inflamed tissue that will heal after conservative vital pulp therapy

• Symptoms can be very misleading in this diagnostic category, from none at all to very intense and sharp sensation associated with thermal stimuli.

Reversible Pulpitis

• The history of symptoms will most often reveal pain or sensation on stimulation only, such that the tooth will only bother the patient when the tooth is exposed to a stimulus that is hot and/or cold

• According to the classification, reversible pulpitis should heal once the irritant is removed or, in case of an exposed dentin surface, the exposed dentin is adequately sealed.

Sudden, mild-to-moderate pain on exposure to extremes in temperature; usually most dramatic to cold stimuli.

Sweet or sour foods or beverages also may cause pain.

Pain does not occur without stimulus and subsides rapidly when removed.Tooth responds at lower threshold to electrical stimulation; mobility and sensitivity to percussion absent.

Sudden, mild-to-moderate pain on exposure to extremes in temperature; usually most dramatic to cold stimuli.

Sweet or sour foods or beverages also may cause pain.

Pain does not occur without stimulus and subsides rapidly when removed.Tooth responds at lower threshold to electrical stimulation; mobility and sensitivity to percussion absent.

Reversible Pulpitis

Moderate carious lesion results in a localized pulpitis. Since nothing in the history points to irreversible pulpitis, it is assumed that after vital pulp therapy this pulp

inflammation will heal.

Moderate carious lesion results in a localized pulpitis. Since nothing in the history points to irreversible pulpitis, it is assumed that after vital pulp therapy this pulp

inflammation will heal.

Clinical Characteristics of Irreversible Pulpitis

• Sharp, severe pain upon thermal stimulation that continues after stimulus removed.

• Cold is especially uncomfortable although heat, sweet or acids can elicit (provoke) pain. Later heat intensifies and cold relieves pain.

• Pain can be spontaneous, continuous and exacerbated when lying down.

• Early response at low then later at higher threshold to electrical stimulation or not at all.

• Pain localized early then more diffuse.• Pain becomes throbbing and keeps the patient awake at night.

Clinical Characteristics of Irreversible Pulpitis

• As with reversible pulpitis, symptoms can be very misleading. It has been well documented that in most cases a pulp that is irreversibly inflamed is asymptomatic.

• It has been reported that dental pulps can progress from vitality to necrosis without pain in 26–60% of all cases

Clinical Characteristics of Irreversible Pulpitis

• According to a recent study, neither gender nor tooth type appears to matter in case of asymptomatic pulpitis; however, the older the patient was (over 53 vs. under 33 years of age) the less likely there was any pain associated with the pulpitis

Painless Pulpitis

Chronic Hyperplastic PulpitisPulp Polyp

• Uncommon form of pulpitis in which an inflammatory hyperplasia (granulation tissue) extrudes to fill a large cavity in the crown

• Usually seen in children or young adults• Deciduous or permanent mandibular molar

most likely to be involved• Apex of affected permanent tooth often

incompletely formed

Chronic Hyperplastic PulpitisPulp Polyp

Periapical diagnosis

• The term apical periodontitis implies that there is inflammation in the periapical tissues

• Like pulpal inflammation, the periapical inflammation can be symptom free and then may only be diagnosed on a periapical radiograph; – however, it is very important to appreciate that a

periapical lesion is most likely caused by an infection in the root canal system, irrespective of the patient having history or being symptomatic

PERIAPICAL DISEASE

Classified as:

– Acute Apical Periodonitis

– Acute Apical Abscess

– Chronic Apical Periodontitis(Suppurative Apical Periodontitis with sinus tract)

– Condensing Osteitis

Treatment of Periapical Disease

Pulpal status

always dictates treatment

of periapical disease

Periapical Disease

Acute ApicalPeriodontitis

Acute Apical Periodontitis

• Mild to severe inflammation that surrounds or is closely associated with the apex of a tooth.

• Results from:– Irreversible inflammation or necrotic pulp.– Trauma or bruxism of normal or reversibly

inflamed pulpitic conditions.

• Consider vertical fractures, periodontal abscess, and non-odontogenic pain.

Clinical Findings inAcute Apical Periodontitis

• Visual– Check for decay, fracture lines, swelling, sinus tracts, orientation of

tooth, and hyperocclusion

• Palpation– Sensitive (usually on buccal surface)

• Percussion– Moderate to severe (initially use index finger to reduce patient

discomfort)

• Mobility– Slight to no mobility (if moderate mobility exists, check for possible

periodontal condition before continuing)

Acute Apical Periodontitis, con’t.

• Perio Probing– WNL (unless concomitant periodontal disease or vertical fracture

exists)

• Thermal (pulpal symptom)– Response (not prolonged) – consider traumatic occlussion– If response prolonged – consider irreversible pulpitis– No response – consider necrotic pulp

• EPT (pulpal test)– Response – pulp is vital (reversible or irreversible)– No response – pulp is necrotic

Acute Apical Periodontitis, con’t.

• Translumination– Not used unless fractured is suspected

• Selective Anesthesia– Not necessary, offending tooth easily located

• Test cavity– Not necessary

• Radiographic– Periapical image does not show a radiolucent lesion; some thickening

of the periodontal ligament is common

Immediate Treatment ofAcute Periapical Periodontitis

If from irreversible pulpitis:• Pulpotomy or extraction.

If from necrotic pulp:• Root canal therapy initiated or extraction.

If from hyperocclusion:When the pulp is normal or reversibly inflamed, adjusting the occlusion provides immediate relief. Always consider cracked tooth, irreversible pulpitis, or necrotic pulp if discomfort persists.

If from bruxism:A biteguard may be indicated.

Periapical Disease

Acute ApicalAbscess

Acute Apical Abscess

• Acute inflammation of the periapical tissue characterized by localized accumulation of pus at the apex of a tooth.

• A painful condition that results from an advanced necrotic pulp.

• Patients usually relate previous painful episode from irreversible or necrotic pulp.

• Swelling, tooth mobility, and fever are seen in advanced cases.

Symptoms of Acute Apical Abscess

• Spontaneous dull, throbbing, persistent pain; exacerbated by lying down.

• Percussion:– Extremely sensitive

• Mobility:– Horizontal / vertical; often in hyperocclusion

• Palpation:– Sensitive; vestibular or facial swelling likely

• Thermal:– No response

Clinical Findings ofAcute Apical Abscess

Visual:– Check for decay, fracture lines, swelling, sinus tracts, orientation of

tooth, hyperocclusion

Palpation:– sensitive; intraoral or extraoral swelling present

Percussion:– Moderate to severe (initially use index finger)

Mobility:– Slight to none; may be compressible

Perio probing:– WNL (unless have perio disease or vertical fracture)

Acute Apical Abscess, con’t.

Thermal:– No response (pulp is necrotic)

EPT:– No response (false-positive from fluid in canal)

Translumination:– Not used unless fractured is suspected

Selective Anesthesia:– Not necessary, offending tooth easily located

Test cavity:– Not necessary unless vitality is suspected

Acute Apical Abscess, con’t.

Radiographic:• Thickening of the periodontal ligament is common; may not show a frank

lesion

If tests indicate pulp vitality: Review diagnostic information (repeat diagnostic tests)• Rule out lateral periodontal abscess• Review medical history for previous malignant lesions or

other conditions (hyperparathyroidism) that may explain contradictory information

• Do not begin treatment until this discrepancy has been resolved

Treatment of Acute Apical Abscess (necrotic pulp)

Minimum immediate treatment (if not extraction)

• Partial instrumentation of canals:– Remove all decay, evaluate restorability– Determine working length of all canals– Achieve apical patency all canals with #10 file, look for

drainage and allow to continue until it stops– Large canals: up to #40 file, 4mm short of WL– Smaller canals: up to #25 file, 4mm short of WL– Alternate with #8 or 10 patency file– Copious irrigation with sodium hypochlorite (1%)– Dry chamber with cotton pledget

continued on next slide

Treatment of Acute Apical Abscess, con’t.

– Place Ca(OH)² into all canals– Place dry cotton pellet in chamber, cover with cavit,

temporarily restore with Ketac-fill, and completely relieve tooth from occlusion.

– Incision and drainage may be required– Prescribe antibiotics and analgesics

Continued pain and swelling are common postoperative problems – so prepare the patient for several days of discomfort.

Periapical Disease

Chronic ApicalPeriodontitis

Chronic Apical Periodontitis• Results from prolonged inflammation that has eroded

the cortical plate making a periapical lesion visible on the radiograph.

• Caused by a necrotic pulp, the lesion contains granulation tissue consisting of fibroblasts and collagen (with macrophages and lymphocytes).

• Must rule out central giant cell granuloma, traumatic bone cyst, and cemental dysplasia.

• Usually asymptomatic, but in acute phase may cause a dull, throbbing pain.

Chronic apical periodontitis. Extensive tissue destruction in the periapical region of a mandibular first molar occurred as a result of pulpal necrosis. Lack of symptoms together with presence of a radiographic lesion is diagnostic.

Chronic Apical Periodontitis, con’t.

• Most common pitfall is assuming that the presence of a periapical lesion automatically indicates a necrotic pulp.

If tests indicate pulp vitality: (red flag!)• Review diagnostic information (repeat diagnostic tests)

• Rule out lateral periodontal abscess, central giant cell granuloma, traumatic bone cyst, and cemental dysplasia.

• Review medical history for previous malignant lesions or other conditions (hyperparathyroidism) that may explain contradictory information

• Do not begin treatment until this discrepancy has been resolved

Periapical radiolucencies associated with mandibular incisors. These teeth were vital, and a diagnosis of cemental dysplasia was made.

Treatment of Chronic Apical Periodontitis (necrotic pulp)

• If asymptomatic, no immediate treatment needed; schedule for root canal therapy

• If in acute suppurative phase, immediate treatment same as with acute apical abscess, i.e.,

• Partial instrumentation of canals:– Remove all decay, evaluate restorability– Determine working lengths of all canals– Achieve apical patency all canals with #10 file, look for

drainage and allow to continue until it stops– Large canals: up to #35 file, 4mm short of WL– Smaller canals: up to #25 file, 4mm short of WL– Alternate with #8 or 10 patency file

Treatment of Chronic Apical Periodontitis, con’t.

– Copious irrigation with sodium hypochlorite (1%)– Dry chamber with cotton pledget– Place Ca(OH)² into all canals– Place dry cotton pellet in chamber, cover with cavit,

temporarily restore with Ketac-fill, and completely relieve tooth from occlusion.

– Incision and drainage may be required– Prescribe antibiotics and analgesics

Continued pain and swelling are common postoperative problems – so prepare the patient for several days of discomfort.

Periapical Disease

CondensingOsteitis

Condensing Osteitis

• Increased trabecular bone in response to persistent irritant diffusing from the root canal into the periradicular tissue.

• May be either asymptomatic (pulpal necrosis) or associated with pain (pulpitis).

• Therefore, may or may not respond to diagnostic tests, i.e., thermal, electric, palpation, percussion.

• Root canal treatment, when indicated, may result in complete resolution.

Inflammation followed by necrosis in the pulp of the first molar has resulted in the diffuse radiopacity of the periradicular tissue.

Pulp Vitality Tests

Pulp Vitality Tests

• Pulp testing is often referred to as vitality testing.

• Pulp vitality tests play an important role in diagnosis because these tests not only determine the vitality of tooth but also the pathological status of pulp

Pulp Vitality Tests

• Various types of pulp tests performed• Thermal test

– Cold test– Heat test

• Electrical pulp testing• Test cavity• Anesthesia testing• Bite test.

Thermal Test

• The response of pulp to heat and cold is noted.

• The basic principle for pulp to respond to thermal stimuli is that patient reports sensation but it disappears immediately.

• Any other type of response, i.e. painful sensation even after removal of stimulus or no response are considered abnormal.

Thermal Test-Cold test

• The basic step of the pulp testing, i.e. individually isolating the tooth with rubber dam is mandatory with all types.

• Use of rubber dam is specially recommended when performing the test using the ice-sticks because melting ice will run on to adjacent teeth and gingivae resulting in false-positive result.

Thermal Test-Cold Test

• Commonly used methods for performing cold pulp test are following

• Spraying cold air directed against the isolated tooth• Application of cotton pellet saturated with ethyl

chloride • Spray of ethyl chloride after isolating tooth with

rubber dam (The ethyl chloride evaporates so rapidly that it absorbs heat and thus, cools the tooth)

Thermal Test-Cold Test

• Application of dry ice on the facial surface of the tooth after isolating the oral soft tissues and teeth with gauze or cotton roll. The frozen carbon dioxide (dry ice) is available in the form of solid sticks having extremely low temperature. It should not come in contact with oral tissues because soft tissue burns may occur

Thermal Test-Cold Test

Cold test using a cotton pellet saturated with ethyl chlorideCold test using a cotton pellet saturated with ethyl chloride

Thermal Test-Heat test

• It is most advantageous in the condition where patient’s chief complaint is intense dental pain upon contact with any hot object or liquid. It can be performed using different techniques.

Thermal Test-Heat test

• The easiest method is to direct the warm air to the exposed surface of tooth and note the patient response.

• If a higher temperature is needed to illicit a response, then other options like heated stopping stick, hot burnisher, hot water, etc. can be used.

Thermal Test-Heat test

• Heated gutta percha stick is most commonly used method for heat testing

• Tooth is coated with a lubricant such as petroleum jelly to prevent the gutta percha from adhering to tooth surface.

• The heated gutta percha is applied at the junction of cervical and middle third of facial surface of tooth and patient’s response is noted.

Thermal Test-Heat test

• The other methods of heat testing isthe use of frictional heat produced by rotating polishing rubber disk against the tooth surface.

• One more method of heat test is to deliver warm water from a syringe on to the isolated tooth to determine the pulpal response.

• This method is especially useful for teeth with porcelain or full-coverage restoration

Thermal Test-Heat test

• The patient may respond to heat or cold test in following possible ways:– Mild, transitory response to stimulation show

normal pulp. – Absence of response in combination with other

tests indicates pulp necrosis. – An exaggerated and lingering response indicate

irreversible pulpitis.

Electric Pulp Testing

• Electric pulp tester is used for evaluation of condition of the pulp by electrical excitations of neural elements within the pulp.

• The pulp tester is an instrument which uses the gradations of electrical current to excite a response from the pulpal tissue.

• A positive response indicates the vitality of pulp. No response indicates nonvital pulp or pulpal necrosis.

Electric Pulp Testing

• Isolation of the teeth to be tested is one of the essential steps to avoid any type of false positive response.

• Apply an electrolyte on the tooth electrode and place it on the facial surface of tooth

• One should note that there should be a complete circuit from electrode through the tooth to the body of the patient and then back to the electrode.

• If gloves are not used, the circuit gets completed when clinician’s finger contact with electrode and patient’s cheeks. But with gloved hands, it can be done by placing patient’s finger on metal electrode handle or by clipping a ground attachment onto the patient’s lip

Electric Pulp Testing

• Once the circuit is complete, slowly increase the current and ask the patient to point out when the sensation occurs.

• Each tooth should be tested 2 to 3 times and the average reading is noted. If the vitality of a tooth is in question, the pulp tester should be used on the adjacent teeth and the contralateral tooth, as control

Test Cavity

• This method should be used only when all other test methods are inconclusive in results.

• Here, a test cavity is made with high speed number 1 or 2 round burs with appropriate air and water coolant.

Test Cavity

• The patient is no anesthetized while performing this test. Patient is asked to respond if any painful sensation occurs during drilling.

• The sensitivity or the pain felt by the patient indicates pulp vitality.

• Here, the procedure is terminated by restoring the prepared cavity. If no pain is felt, cavity preparation may be continued until the pulp chamber is reached and later on endodontic therapy may be carried out.

Anesthesia Testing

Bite Test

Bite Test

Patient is asked to bite on cotton swab or hard object for bite testPatient is asked to bite on cotton swab or hard object for bite test

Recent Advances in Pulp Vitality Testing