DIAGNOSTIC TESTS 2

Last

time we talked about diagnostic tests and we talked about vitality test including (electric pulp test, heat test, cold test) and today we will continue talking about other diagnostic tests. 1) Percussion test 2) Mobility test 3) Calibrated probe 4) Radiograph 5) Palpation 6) Needle aspiration 7) Transillumination 8) Detection of caries
You

should notice that the topic of the lecture does not correlate to what we are doing in the clinic because we dont have all the instruments in the teaching center, but the reason to mention it is just to know that they are in the market.
You

will do vitality test and radiographic test to diagnose and reach treatment planning.

Lets start (slide 2):

1--> Percussion test ))

At which clinic we do this test? We do this test in the ITU, perio, surgery, pedo for example in patient having dentoalveolar trauma in order to manage where it is. >> So you tap the tooth carefully by the tip of the handle of the mirror or the blunt tip of the probe or another instrument, you evaluate the tone which is the resulting sound and you evaluate if there is any tenderness to percussion (patient reaction).

Tenderness to percussion happen when we have periodontal ligament injury.

> NOTE : always remember that you should start with sound contralateral tooth and test more than one tooth, EX: when we want to test the right mandibular first molar in the you need to start with the left mandibular first molar (sound tooth) if it wasn't sound, you test the molar next to it.

If the patient have periodontitis you should maintain a great caution because the percussion creates severe tenderness(pain).

If the patient have dento-alveolar trauma specially in children, dont use the handle of the mirror or any instrument, use your finger gently (digital pressure) to evaluate the pain.

Slide (3) :

Percussion test >> Percussion test interpretation :

> Healthy teeth with intact periodontal ligament will produce a low dull tone . >> If the tooth intruded / locked into bone or ankylosed it will produce high metallic tone . >>> If the tooth extruded or subluxation Slide (4) :

Percussion test >> Types

1) Vertical percussion (apical): If you use this method and the patient have pain then the most likely he have apical periodontitis . 2) Horizontal percussion (lateral): If you use this method and the patient have pain then the most likely he have lateral periodontitis or periodontitis of gingival origin. 3) Finger (Digital pressure) >> If the patient have dentoalveolar trauma use youre finger (digital pressure). Slide(5) : Application of both horizontal, vertical percussion

Slide(6): Its extruded from the socket -> dull tone Slide(7) : In this case it's not advisable to use the handle of the mirror for percussion because it would bs severely painful. Slide( 8-12):

2--> Mobility test

Which's used to evaluate the periodontal ligament or the status of the teeth in cases of trauma, periodontal disease. We need to know about the mobility to establish a treatment plan.
Its

done by using: 1) Two instruments (handles of the mirror+another instrument) 2) Finger and another instruments' handle. Slide(9): In order to determine the degree of mobility you need: 1)Horizontal tooth mobility Two instruments are used in facial-lingual direction to determine the horizontal mobility. 2)Vertical tooth mobility >> You depress the tooth in the socket.

There is a calibrated probe that test the force you apply to determine the tooth mobility, its used mainly in research and experimental purposes. (slide 10)

:: Classification of mobility ::

There are many classifications but the doctor talked about this

1) Class 1: Slight mobility, up to 1mm of horizontal displacement in facial-lingual direction. 2) Class 2: Moderate mobility, greater than 1mm of horizontal displacement in facial-lingual direction. 3) Class 3: Severe mobility, greater than 1mm displacement in facial-lingual combined with vertical displacement (tooth depressible in the socket). slide(11) What are the causes of increased mobility 1) Reduced bone support 3) Crown or root fracture 2) Abscess or inflammation of PDL 4) Bone fracture

If the tooth exhibit full mobility it can be root fracture or bone fracture >> In bone fracture you are expected to see more than one tooth exhibit loosening. (the doctor did not mention anything about root fracture but I think we can use Lateral percussion test as a diagnostic tool for Horizontal root fracture, beside taking an appropriate radiograph of course).

Sometimes its difficult to determine crown or root fracture or bone fracture.

NOTE : It's rarely that one test will provide an adequate information to make diagnosis and treatment plan. (slide 13-18):

3--> Calibrated probe

This test is routinely used in Periodontics to measure sulcus and pocket depth. Also its used to determine the size of intra-oral lesion or deviation (remember

when we talked about the extra-oral examination to measure jaw movement and mouth opening we used the ruler but in the deviation we use calibrated probe if the deviation was up to 9mm (some patient exhibit more than that) .
We

use it also to measure overjet and overbite.

>> Now if you find oral lesion in the mouth you need to describe it in order to follow up and asses improvement of your treatment, for EX: you noticed a swelling

in the oral cavity, you have to document color, size, location, shape and texture, because its very important in follow up treatment to know if there is any increase/decrease in the size or another change in any other feature. slide (14) There are many forms of calibrated probe in the market, the best one to use is the one that marked with( mm ). slide (15)

Thats what we are doing to evaluate the depth of the sulcus using calibrated probe, in healthy mouth the depth of the sulcus should be from (1-3mm). slide(16): This tooth exhibit periodontal involvement because the depth was 6mm. slide(17)

Some probes use stent to reproduce the same position when measuring the depth (for accuracy and reproducibility) slide (18)

This is an oral lesion in the palate you need to measure the size, hight of the lesion and record it in the dental record, you can use calibrated probe if the lesion is less than 9mm, we should document the size (anteroposterior, mediolateral).

Slide 19-22

4--> Radiograph
>> Should be done (you will do it the next week). You know radiographs don't lack risk factors, although the exposure is limited.
Always

in the first visit you should take radiograph as its important to detect diseases such like incipient caries as contact areas cannot be detected by visual inspection or probing).
In Europe, Bitewing

Australia, USA there is a guideline but here we dont have a guideline, we use our clinical judgment all the time!! radiographs must be taken in the first visit for all patients, especially when there is closed contact area to evaluate proximal surfaces.
Periapical

radiograph taking according to your judgment.

What are the guideline for prescribing a radiograph? The FDI guideline says: 1) If the patient is new, adult, dentate, partially edentulous: full mouth intra-oral radiographic exam is preferred when the patient have a tendency to develop caries.

2) If the patient is new, adult, edentulous: you take radiograph as the need, based on clinical signs and symptoms.

If you dont take a radiograph for proximal caries detection also failed to detect it clinically -> wrong decision.

If you dont take a radiograph for proximal caries detection and you detect it clinically-> right decision. Slide (20):

Recall patient;

If the patient has clinical caries or in increased risk of caries -> posterior bitewing exam in 6-18 months interval.
If

the patient doesn't have clinical caries or not at risk for caries-> posterior bitewing in 24-36 months interval. NOTE: The slide is wrong it's decreased risk of caries not increased. These recommendations are subject to clinical judgment if the patient has much many radiographs or you can use another instrument to establish diagnosis and plan the treatment, there is no need to follow these guidelines. (slide 21):

Radiation protection

The recommendations in Australia, Europe ,Jordan are there's no need to use apron,(the doctor recommends to use apron especially when the patient ask for it).

FDI recommendations: the thyroid shielding shall be provided for children because the thyroid gland is highly successible to cancer, and should be provided for adult if not interfere with the examination, if it interfere with the diagnosis avoid it, (your decision should always be for the interest of your patient).

Scenario: If the patient come for radiograph asking for thyroid protection, you tell them thats there is no need according to the guideline, after 5-10 years the patient developed thyroid cancer and he may come back to you and says thats this your responsibility. Slide (22): 1) Incipient caries lesion cant be visualized and cant be detected by probe so bitewing radiograph is a must in the first visit and in recall visit whither if patient at high risk caries or doesnt exhibit tendecity to develop caries lesion. 2) Apical radiograph also used to evaluate Periapical lesions and furcation involvement in the case of periodontal disease. 3) In case of overhanging restoration where there's recurrent caries underneath it, you cant make a diagnosis without ordering radiograph. 4) In case of proximal amalgam restoration and the gingiva is inflamed. In that lesion you cant detect it without radiograph.

5) In old recommendations, full mouth screening including OPG to detect Periapical disease of anterior teeth (Ex: bone disease). (slide23):

5--> Palpation
is used as apart of physical examination in which an object is felt to determine its size, shape, firmness, location wiki

Dr just said: in case of anxious, younger patient wherever you touch whatever you do and sometimes even before you touch them they are tender leading to difficulty in decision, you will not know if the ligament is involved for example.

If you are suspicious that you have Periapical lesion or abscess you can touch/palpate the Periapical area with your finger if there tenderness it may help you . (Slide24-29):

6--> Needle Aspiration

Used for evaluation of cyst or radiolucency The needle that we use (21-25 G).

within the bone.

Syringe that we use (in the slide written 20 ml but the Dr said it's 10-12 ml and it depends on the size of lesion)
You

will do aspiration to the fluid within the radiolucent lesion and this is sometimes useful to make a diagnosis for Ex: you can differentiate between radicular cyst and keratocyst depending on the aspirated material. How is this helpful (slide25):
If If If

there's a radiolucency and nothing is aspirated -> solid lesion the aspiration was air -> solitary bone cyst

the aspiration was blood -> vascular lesion :an important thing if you suspect vascular lesion (hemangioma, arterio-vascular malformations), it's very useful to make aspiration because the treatment plan of such vascular disease differ than the treatment plan of excision radicular cyst. The difference is that the vascular lesion should be managed in the hospital and the surgeon should be prepared to deal with excessive bleeding, but in case of radicular cyst, managing it can be done with local anesthesia, the precaution is not as we deal with vascular lesion.
If If If

the aspiration include pus -> abscess or infection the aspiration include keratin -> odontogenic keratocyst the aspiration containing crystals -> periodontal or dentigerous cyst

>> So aspiration is very useful because you will not do incision of the lesion to know what it is. (We know that in incision we give local anesthesia & making

incision, send it to the histopathology, and maybe removing it by excision of the biopsy after knowing the nature of the lesion). So aspiration is less invasive and cost effective. Slide (26): :: This patient has radiolucent legion, there are many differential diagnosis for this lesion: 1) Odontogenic cyst 2) Solid lesion as ameloblastoma 3) Soft tissue lesion within the bone 4) Vascular lesion Slide (27): ::>> By this aspiration you can exclude infection because there is no pus and you can exclude vascular lesion because there is no bleeding in the aspirate. NOTE: Diagnosis of unicystic plexiform ameloblastoma was not made by aspiration, it was diagnosed by histopathology. Slide (28): :: This aspirate is keratin and as we said it's more likely to be keratocyst or odontogenic kerato tumor (which is the suggestive terminology of keratocyst). Slide (29): :: This aspirate may be pus or it may be keratin, to differentiate between them we use our smell sense.

No smell -> keratin Slide (30-36):

smell ->pus >>>>> Here we have keratin

7--> Transillumination

In the clinic we use it a lot to evaluate fractures and cracks of the crown, in other specialty we use it to evaluate sinusitis. >> This method depends on the reflection of the light and the interpretation of the color that result from the reflected light. 1) If the light that is reflected was reddish or orange color it's suggestive of muscular and fatty tissue. 2) If the light that reflected was purple or black color it's suggestive of blood vessel. 3) In case of cracks the color will be black.

Now the instrument that we use in Transillumination

They are many instruments in the market which is based on fiberoptic light. 1) We can use hand held Transillumination. 2) Composite curing light (we will use it in the clinic).

3) You can use reflection of light by the mirror if you dont have composite curing machine. Uses of dental mirror: 1) Indirect visualization 2) Retraction 3) Reflection of the light Slide (31)

As a role >>
> If the entire tooth lights up and there is a shallow black fracture line the tooth intact > If half of the tooth lights up and the other half is white -> deep crack slide(32):

Uses of Transillumination :
1) They are used to diagnose teeth that have cracks. 2) Interproximal caries. 3) Maxillary sinusitis. NOTE: In the book these 3 mentioned uses should be done in a dark room . Slide (33):: This is the test of Transillumination. Slide (34):: There is another advanced technique, its a useful test.

Slide (35): This a microlux Transilluminator, it's very very small pin like which shows the caries as a dark shadow Slide(36): Tooth sloth >> is another method to diagnose cracks, we may use this plastic sloth or cotton roll and ask the patient to bite on it, if he have a crack the patient will develop very severe pain suddenly, you can also confirm your diagnosis by the Transillumination (its better). Slide 38

8--> Caries detection

We use diagnodent (cario diagnodent) as an adjunct to monitor and assure early carious lesion.
By

using the diagnodent we are more objective with all patient unlike the use of probe which is subjective from one patient to another.
The

way that diagnodent work is by measuring the amount of fluorescence detection the examined teeth this fluorescence shows on the screen within the diagnodent.
Value

of fluorescence correlated to caries experience. >>0-13 -> indicates healthy teeth and the suggested treatment is only prophylaxis.

>>14-20 -> indicative of enamel caries and the treatment is intensive professional cleaning and fluoridation, if the patient is at high risk caries do fissure sealing. >>21-29 -> indicative of deep enamel caries and the treatment is to restore the tooth. >>30 -> indicative of dentin caries. :: So we depend on the value that comes with the device.

You can use the diagnodent for monitoring the caries on the follow up visit Ex: if the value of the fluorescence was 0-13 then in the next visit it become 30 the caries in this case is progressive and does not show arrest. Slide (38): As we said we use tooth sloth or cotton roll as an alternative to detect cracks or fractured teeth.

Done By :: Rana Gmal Eg'barie,Omama Abu Swees

Special thank to my dear Basheeryeslamo kteeeer A7la ehda2 l27la sa7bat bl3alm ,,rasha,3ren,Hana2,yara,esra2 wa7sn shreke bl3alm smo7aa