The proper diagnosis of any diseased condition with the help of application of knowledge to gauge and correlate the various symptoms and judicious use of various examination techniques and aids, is of paramount importance for successful completion of the treatment. The accurate diagnosis is always the first step of the successful endodontic treatment.
Subjective symptoms are apparent only to the patient, like the tooth sensitive to hot or cold or pain at night.
Objective symptoms, or signs, are evident to the observer, like the swelling or broken down tooth.
Extraoral examination is used to determine swelling that can be easily seen by just looking at the patient and also by palpation of the lymph nodes to diagnose additional pain and swelling.
The patient is first questioned regarding the location, duration, and type of pain he or she is experiencing (dull, throbbing, stabbing, etc.). If the patient is able to distinguish which tooth may be causing the problem, this tooth is used as a starting point. The most obvious tooth is examined first, particularly if the patient, the symptoms, and/or signs (such as large restorations, caries, or fistulas) call attention to a certain tooth. The condition of the tooth as a whole should be observed. Direct examination of the tooth may reveal a caries, an exposed pulp, a hyperplastic pulp, or an almost-empty root canal. If the pulp is exposed, its colour, consistency, and odour should be observed. When the condition warrants, the dentist should look for a fistula, Although extraoral swelling may be obvious, the mucosa may need to be palpated to determine if any intraoral swelling is present.
Radiographs help in visualizing what we can not see because tissue and bone cover most of the tooth. They are used widely in the Endodontic treatment, not only to diagnose the pathologic condition of the pulp, but also as an aid to measure and locate the various significant anatomic structures during the endodontic treatment. Radiographs are of great help in locating and measuring the root canals of the tooth needing Endodontic root canal treatment.
PERCUSION AND PALPATION
Percussion is a dental diagnostic procedure in which the crown of the tooth is struck with a quick, moderate blow (with the tip of the finger or an instrument) to determine whether a tooth is tender or not. Tenderness may also indicate that periodontitis is present.
Palpation is the act of determining by touch or slight pressure the consistency of the tissue beneath the fmgertips. Palpation is used to find out whether swelling is persistent and whether the involved tissue is hard or soft, rough or smooth, and so forth. It is generally used where an abscess is suspected.
The mobility test is the act of moving a tooth with the fingers or two instrument handles in order to determine whether it is loose. Mobility tests are used to determine the presence of infection and related bone destruction of periodontal disease. In case of periapical abscess also, the tooth mobility increases in some cases.
THERMAL SENSITIVITY TEST
Thermal (hot or cold) stimuli such as ice and heated gutta percha have far more value as testing methods when the teeth in general are already sensitive to temperature changes.
Reaction to thermal stimuli will be either positive response or a negative response. Application of heat can cause a positive response, particularly if the pulp is hypersensitive or inflamed. Both hot and cold stimuli bring about a reaction from a hypersensitive or hyperemic pulp. Cold is more apt to cause a response than heat. With true hypersensitivity or hyperemia, the sensation fades away upon removal of the stimulus. When pulpitis is present, the pain continues after the stimulus is removed, sometimes for several minutes or longer.
Cold as a stimulus is completely negative in a necrotic tooth. Heat rarely elicits a response from the necrotic pulp but may bring about a slight sensation from the chronically inflamed pulp.
During a transillurnination test, a strong fiberoptic light is shown through the teeth while holding a mouth mirror in the shadow on the lingual side. The variance in color from tooth to tooth is observed in the reflection. This technique is also used to determine if a fracture exists in the coronal portion of the tooth.
A test cavity may be prepared by applying a bur to a tooth to enter the dentin without anesthesia being administered. This procedure is done as a last resort to determine the presence or absence of pulp vitality, especially with teeth having advanced pulp recession that does not respond to any other method of testing.
ELECTRIC PULP-VITALITY TEST
Electric Pulp Tester
This test is of significant importance in measuring the vitality of the pulpal tissues. The electric pulp tester, also known as Vitalometer, measures sensory nerve response of the pulpal tissues to a current of electricity. With help of vitalometer the current is made to pass through the dense layers of enamel and dentin.
The denser the enamel and dentin layers of the tooth, the greater the amount of current required to induce response. The absence of any electric stimulation is indicative of the non-vitality of the pulpal tissues and may need endodontically removal of pulpal tissue (Root Canal Treatment). The electric pulp vitality test should not be used on any patient with a cardiac pacemaker.