Diagnostic Tests

Few notes before beginning our lecture as the doctor said : about intraoral examination you have to: * check the buccal mucosa.. *check the orifices of parotid glands *check the foliate papillae and any granules on the tongue *check everything that we learnt in previous lectures to differentiate normal anatomy from abnormal.

Diagnostic tests
There is no treatment without taking history and chief complaint . There are tests that we do routinely in dental clinic and tests that we do in the laboratory In the clinic we do routinely dental test for diagnosis any non vital pulp

Routine Dental Tests

Vitality tests: - Thermal: cold and heat - Electrical - Cutting an access cavity without anesthesia -1-

In general we do thermal test (cold is preferable than heat) if doesn`t work we do alternative test which is electrical test and if it doesn`t work due to inflammation we do another method what`s we call latitude test (not sure about the name) this test we cutting an access cavity without anesthesia and if the pt feel pain when we reaching the dentine we conclude his tooth is vital .. Before we doing vitality test we have to take history chief complaint radiographs after that we do vitality test .. Vitality tests Provide an adjunct to determining the state of pulp Sometimes we need to do more than one vitality test to reach the exact diagnosis.. Results must be interpreted with caution

You should know that you may face False positive and false negative results and this common in vitality test be careful ex. Syphilis is associated with stigma and the result is positive you have to be familiar with each test and rule out the result That`s why we doing more than one test.

Surrounding and contralateral teeth should also be tested to compare between the result and knowing the non vital teeth.. Test should begin on a normal tooth because there are pts tell you all their teeth are painful when you touch everywhere is tender including vital teeth that`s why you should begin on a normal tooth Stimuli should be applied to normal enamel of the crown of the tooth not to restorative material or soft tissue to avoid either false negative or false positive -2-

 Better results if more than one test is used ( heat and cold, or cold and electrical tests to compare the results as we said

Uses Of Vitality Testing In Clinical Practice

*-* Prior to operative procedures before doing access cavity do vitality test to know that you should to do amalgam restoration or RCT make sure that you have a time to do operative procedures don`t prepare an access cavity if you don`t have enough time to finish your work .. *-* Diagnosis of pain you have to differentiate between the pain of the teeth and the pain from nausea

*-* Investigation of radiolucent areas especially in periapical lesions are from pulpal origin not a cyst or periapical abscess or normal anatomy like mental foramen in between premolars area *-* Post-trauma assessment like fracture in the mandible or dislodged teeth we repositioning the tooth and we do vitality test to check if it`s vital or not *-* Assessment of anesthesia .. before giving LA we want to know if the tooth is painful especially in children *-* Assessment of teeth which have been pulp capped or required deep restoration to know if the tooth still vital

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*Thermal Vitality Tests*

*-* A temperature in the range of 20-50 C does not elicit pain from healthy teeth Teeth with inflamed pulps (pulpitis) react with severe pain on temperature stimulation within 20-50 and this is the rational way to check if the tooth is vital

1)

Cold Test

Involves using a refrigerant, such as endo-ice(we use in the clinic) ( ) , ethyl chloride spray .. some dentist use the ice from the refrigerator or fill the carpool of LA water and putting it in the refrigerator and using it as ice and do this test .. The doctor doesn`t advice this method (filling the carpool water to avoid cross infection) The pts who have caries know when drinking cold water the teeth start to be painful and this is the principle of this test We put the ethyl chloride spray on The middle third of the clinical crown for posterior teeth and the border between the coronal and middle thirds of the clinical crown for anterior teeth (always choose the sound enamel )

*How to Apply the Cold Test*

Hold a cotton pellet in tweezers and Spray Ethyl chloride or endo ice until crystals form and Apply the icy pellet to the facial surface of the tooth then Leave the chilled cotton pellet on the tooth for at least 10 seconds before deciding on the response and tell the patient to rise his hand when you feel pain

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1.endo ice

2. cotton pellet in tweezers 3. Apply the icy pellet to the facial surface of the tooth

If the patient rise his hand and his tooth is painful and the pain sharp and linger it`s a symptom of irreversible pulpitis. If the pain sharp and doesn`t linger it`s a symptom of reversible pulpitis.

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If there is no pain (no response to cold test ) we have to think about pulpal necrosis or we have to do another test which is EPT in case of non responsive to cold test In case of sclerosis of the canals..

2) Heat Test Apply to the vaseline-coated surface of the test tooth to adhere to the tooth Use a ball of softened gutta percha on the tip of a plastic instrument (guttapercha softens at 65 C) This test is difficult because we have to heat the gutta percha at 65 C and we dont know the exactly temperature while heating it Place the gutta percha onto the tooth the same way you would the ice Wait approximately 5 seconds (in the book written 15 sec but the doctor said it`s too long and 5sec is enough) Compare the results from other tested teeth

1.Apply to the vaseline-coated surface of the test tooth

2. A rubber cup applied to a tooth to generate frictional heat

The use of hot water, administered through an irrigating syringe under rubber

dam isolation (can we use this method in cold water test to isolate the non vital tooth when we suspicious )

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Disadvantages:
*-* May be difficult to use on posterior teeth because of limited access *-* Excessive heating may result in pulp damage *-* May result in a lingering pain, therefore heat tests should be applied for no more than 5 seconds *-* Inadequate heating of the gutta-percha stick could result in the stimulus being too weak to elicit a response from the pulp

* Electric Pulp Test (EPT) *

*-* EPT it is easy but it`s technique is sensitive *-* Make sure the tooth must be clean and dry before toy apply the device *-* The anatomic location should have no restoration, orthodontic band or brackets, or arch wire *-* An adequate medium to transmit the electric current to the tooth ex. ( gel, toothpaste)should be applied having contact between the tooth probe and tooth for a completed electrical circuit

*How To Conduct The EPT*

Before beginning, provide the patient with specific instructions to raise a hand or arm when a sensation occurs (when there is pain) and bring down his hands when there is no pain Clean , dry and isolate the tooth Use a small amount of toothpaste on the metal tip of the probe (in the clinic there is gel ) and we can use anything else to provide transmitting the current between the probe and the enamel -7-

 Place the tip on the middle of the facial surfaces of the tooth Do not place the probe on a restorative material (metal, composite, ceramic) or touch gingival tissues because these materials give us false positive !!!! (exaggerated response to the test)

The probe should not touch lips or cheeks

Have the patient touch the handle of the device with a finger ( in order to ground the unit to complete the electric circuit) Start by pressing and holding the start button Gradually increase the voltage until a response is elicited (you can set the voltage either medium or high. The doctor said keep it medium) - When the patient indicates a response, release the start button The reading will be fixed on the display for some time after the button is released the reading is stays on the screen up to 5 min !! ex. 40 voltage is the positive response A response to the maximum reading (e.g. reading of 64 is usually indicative that the pulp of the tooth being tested is nonvital) If we reach the max. reading we conclude that pulp is not vital!!

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*-* Between 0-40, the patient feels ache; vital pulp

*-* Between 40-80,with abovementioned reaction, partially vital pulp (one or more canals are vital in multi rooted teeth )

*-*80, no mentioned reaction, non-vital pulp

There are many of devices you should read all the manufacture instruction of each device and the max. voltage of each one .. there are many types of devices some of them here and you can see the others in GOOGLE .
A hook on the patients lip completes the circuit Electrical conducting gel is present between the electrode and the tooth

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Electric Pulp Test (EPT):

Some dentists say we can start with Electric Pulp Test and the others say that test should be used when the hot and cold tests fail to give clear information on the state of vitality of the tooth In fact they start with cold test (apply air on the tooth from the mouth ) but in this method it`s not easy to know which tooth elicit response when there are many teeth !!! Results must be compared with the response from other teeth

The most desirable area of assessment is at the incisal edge of incisor teeth, and the mid-third region of posterior teeth (on the tip of the mesiobuccal cusp on molars ) because these areas close to the pulp horn

False Positives From EPT Testing

Anxious patients,, some patients say it is painful before the dentist touch them Liquefaction necrosis Contact with metal restorations Vital tissue still present in partially necrotic root canal system

False Negatives From EPT Testing

Incomplete root development -10-

 Recently traumatized teeth Sclerosed canals Recent orthodontic activation Patients with psychotic disorders

Interpretation Of The Results Of Vitality Tests; Positive ( Normal)

The test tooth responds in a similar way and to a similar level of stimulation to the other healthy teeth. If we tested the normal tooth and the reading is 30 V and the reading of the tooth in question (the pt feel pain in that area) and the reading is 30 or 35 V This result suggests that the pulp is vital tooth

Interpretation Of An Exaggerated (prolonged) Response

if the pain stays more than 10 second we conclude the pulp isn`t vital or that pt has irreversible pulpitis.. The test tooth responds more severely than and to a lower level of stimulation to the other healthy teeth. Pain lasts for more than some 15 seconds ( minutes, hours) after removal of the stimulus The response to heat & electrical stimulation may be greater than to cold. Cold may reduce the pain Irreversible pulpitis -11-

 Chronic pulpitis; if gradual reaction to heat, but not to cold or electrical stimulation leads to an exaggerated response

Interpretation Of Negative Response

The test tooth does not respond to stimulation but healthy teeth do The result suggests: Non- vital pulp Root canals are sclerosed

False Positive
As we said in the electric pulp testing give us positive result but the tooth is not vital !! this what we call false positive We face this condition in : *-* The test unhealthy tooth responds normally
False positive the tooth is

*-* Occur in anxious or young patients *-* Contact with metal restorations (electric test) *-* Inadequately dried teeth ( electric test) *-* Multi rooted teeth with one vital root canal pulp *-* In a root canal filled with pus or gas *-* In a patient with low pain threshold

non vital and the patient says I have pain

False negative the tooth is

vital and the patient says I have no pain

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False Negative
Teeth with restorations ( heat and cold test) Teeth with secondary dentine Nerve supply to the pulp is damaged (e.g. trauma) In a patient with a high pain threshold Faulty technique or equipment .. (if you dont use gel in electric pulp test )

Inconclusive Result
All teeth give similar responses: conflictive results If the results of two tests are inconclusive add a third test Consider cutting a diagnostic access cavity without local anesthesia when we reach the DEJ the pt feels pain and we know that tooth is vital

Diagnostic Cavity Preparation

Is the most reliable vitality test This test may serve as a last resort in testing for pulp vitality Is made by drilling through the enameldentine junction of an unanesthetized tooth with good isolation If the patient feels pain once the bur contacts the sound dentin, the procedure is terminated and cavity is restored -13-

Local Anesthetic Test

after using all vitality tests we move to Local Anesthetic Test This is the most difficult situation in the clinic we give anesthesia starting from most posterior teeth either infiltration or intraligamentary injection until the pt doesn`t feel any pain we dont give him ID in the beginning because we couldn`t know which tooth is painful because we anaesthetize the whole area

We use this test When dental symptoms are poorly localized or referred, an accurate diagnosis is extremely difficult Using either inltration or an intraligamentary injection, the most posterior tooth in the area suspected of causing the pain is anaesthetized If pain persists, the tooth immediately mesial to it is then anaesthetized, and so on, until the pain disappears

Assessment Of Pulpal Vascularity

The tests that we talked about are vitality test working on the nerves !!! This test concerns about vascular system in the pulp and We need technique sensitive for this test . This test not widely used in the clinics and we call it under vitality test Crown surface temperature -14-

 Laser Doppler owmetry: a non-invasive , painless technique with direct and objective registrations, but has limitations : environmental and technique-related factors. Nonpulpal signals, principally from periodontal blood flow, may contaminate the signal Pulse oximetry: measure oxygen saturation levels May be the tooth is vital but there is no nerve stimulation in the pulp in such case this tooth is beneficial

Laser Doppler Flowmetry (LDF)

A LDF probe applied to a sectioned tooth showing the passage of light via the enamel prisms and dentinal tubules to the pulp

Note : this test not required for us but who wants to use this test in his clinic and get information that test is exist

THE END
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Done by : ANAS MOHAMMAD AMER -15-