DIAGNOSIS AND TREATMENT PLANNING IN CONSERVATIVE DENTISTRY AND ENDODONTICS Introduction Definition : Diagnosis (According to McGhee Grossman) Differential

tial diagnosis Prognosis Treatment plan (Sturdvent operative dentistr !th edition) "or#ing diagnosis Definition diagnosis $ Pretreatment considerations % % % % % % % &hief complaint Medical 'istor Sociologic and Ps chologic revie() Past Dental 'istor Present *is# Assessment) +,tra oral e,amination Intra oral e,amination a) Soft tissue &harting and records -) 'ard tissue Tooth denotation s stems) c) &linical e,amination of caries) % .cclusal caries) % Smooth surface caries) % *oot caries ii) &linical e,amination of additional defects % Tooth (ear % Developmental defects $ +,amination and Diagnosis

iii) iv) v) vi) vii) viii) i,)

&linical e,amination of trauma +,amination of amalgam restorations +,amination of cast restorations +,amination of tooth colored restorations +,amination of Periodontium +,amination of occlusion +,amination of Pain % Definition (According /ields IASA) % Pulp pain classification (Ingle 0th edition endodontics) % Diagnosing tooth ache)

$ Diagnostic aids in caries) Old Trends 1) 2isual Detection 3) Tactile sensation (ith e,plorers 4) *adiographs !) Temporar elective separation and impression) 0) &aries detector d es) Newer Trends 1) &omputer -ased image anal sis) 3) 5uantitative light induced fluorescence (56/) 4) +lectro conductness measurements (+&.M) !) Digital fi-re optic transillumination (DI/.TI) 0) +ndoscopic filtered fluorescence (+//) 7) Alternating current infedence spectroscop techni8ue) 9) Megnetic resonance micro imaging (M*M) :) ;ltra sonic Imaging <) Diagnodent laser diode fluorescence 1=) Stre field imaging (S/*A/1) 11) *adio visiograph (*2G) 13) &aries activit tests * Diagnostic AIDS in Endodontics 1) 2isual and Tactile Inspection

3) Palpation 4) Percussion !) Mo-ilit and Depressa-ilit tests) 0) Periodontal e,amination 7) *adiographic e,amination 9) >eroradiograph ) :) Digital su-straction radiograph ) Vitalit tests 1) Thermal tests 'eat ? &old 3) +lectric Pulp test 4) Test cavit !) Anaesthetic Test 0) 6aser Doppler /lo(metr (6D/) 7) Pulse .,imetr ) 9) 6i8uid cr stal testing) :) 'ughes pro-e e camera Newer Met!ods % % % % % % ;ltra Sounds *eal time imaging &omputeri@ed Tomograph Magnetic resonance imaging &omputeri@ed e,port s stem) Tuned aperture computed tomograph (TA&T) Infrared Thermograph )

$ Diagnosis of crac#ed tooth s ndrome $ Treatment Planning) 1) ;rgent Phase 3) &ontrol Phase 4) *e%evaluation Phase !) Definitive Phase 0) Maintenance Phase

$ &onclusion $ *eferences Introd"ction Pretreatment considerations consisting of patient assessmentA e,amination and diagnosis and treatment planning are the foundation of sound dental care) These considerations follo( a step (ise progression as the diagnosis and treatment plan depend on thorough assessment and e,amination of the patient) Diagnosis #Is defined as correct determinationA discriminative estimation and logical appraisal of conditions found during e,amination as evidenced characteristic of health or diseaseB) % McG!ee$ Diagnosis Cis the process of identif ing a disease - its signsA s mptoms and results of various diagnostic proceduresB % Gross%an$ Di&&erential diagnosis Is the list of most li#el and possi-l diagnosis -ased on availa-le informationB) The final diagnosis is onl arrived atA after other diseases on this list have -een eliminated through further investigations or consultations) % 'e(ster Dictionar $ Prognosis CPredicting the li#el outcome of a disease -ased on condition of patient and action of disease) % 'e(ster Dictionar Treat%ent )lan CIs a carefull se8uenced series of services designed to eliminate or control etiological factorsA repair e,isting damage and create a functionalA maintaina-le environment) Te*t (oo+ o& o)erati,e Dentistr - St"rd,ent$ C'or+ing diagnosis./ after eliminating as man diseases (differential diagnosis)) /rom distinctive mar#sA signs that are

consideration as the information DustifiesA the remaining possi-ilities are ran#ed in the order of

diagnostic pro-a-ilit ) The most li#el diagnosis is referred to as the C"or#ing diagnosisBA the Cpresumptive diagnosisB or C&linical impressionB or CProvisional diagnosisB Gar C$ Cole%an$ * Additional tests and preliminar treatment limits the list to a single diseaseA (hich is the

CDefinitive diagnosisBA C/inal diagnosisB or Dust CdiagnosisB) The final diagnosis determines the definitive management of the pro-lem Gar C$ Cole%an) PRETREATMENT CONSIDERATIONS * C!ie& Co%)laint % % % Eefore initiating an treatment it is important to determine the patients chief complaint or the pro-lem that initiated o(n (ords) It is recorded in patients o(n (ords) Patient should -e encouraged and guided to discuss all aspects of current pro-lemA including onsetA duration s mptoms and related factors) S %)to%s Are the units of information sought in clinical diagnosis) It is defined Cas phenomena or signs of a departure from the normal and indicative of illnessB) E Gross man) S"(0ecti,e s %)to%s Are those s mptoms ascertained - the clinician through various tests) It thus follo(s that the corners or pillars of a correct clinical diagnosis are a) Good case histor -) A thorough clinical e,amination and c) *elevant investigations F diagnostic tests) Medical !istor % % 2$ Medical histor helps identif conditions that could alterA complicate or contra indicate proposed dental procedures) /or e,ample : 1$ Co%%"nica(le diseases / 2iral infections li#e hepatitisA AIDS that re8uire special precaution procedures or referral) Allergic or %edications / Patients allergic to local anesthetics li#e CGovacaineB ma contra indicate use of certain drugs)

3$ 4$ %

S ste%ic diseases and cardiac a(nor%alities li#e rheumatoid heart diseases that demand less strenuous procedures or proph lactic anti-iotics coverage) P! siologic c!anges associated wit! aging / influence treatment) +ven though there are virtuall no s stemic contraindication to endotherap (e,cept uncontrolled dia-etes or recent m ocardial infarction)A a recentA comprehensive medical histor is mandator ) ma alter clinical presentation and

% % % %

Patients (ith s stemic conditions li#e heart valve replacementA a histor of rheumatic fever or advanced AIDS re8uire anti-iotic proph la,is) Patients (ho are on anticoagulant therap suspended) During endodontic treatmentA clinician must #no( (hat drugs the patient is ta#ing so that adverse drug interactions can -e avoided) In case of patients (ith mental or emotional disordersA medical consultation -efore diagnostic e,amination (ould -e -est) ma need to have the dose reduced or

* Sociologic and Ps c!ologic re,iew$ % % During initial visits the clinician should ascertain the patients attitudesA prioritiesA e,pectations and motivations to(ards dental care) Attitudinal information com-ined (ith assessment of the patients dental appreciationA educa-ilit ha-itsA parental histor A occupation and financial situations can indicate the patients commitment to dental care) % % Diet 5 since diet pla s a maDor role in dental caries and is of importance in tooth (ear) 6a(its 5 it is relevant to en8uire a-out toothA cleaning ha-its and the tooth paste used as (ell as other ha-its) +,ample smo#ing (ill increase the li#elihood of surface stains on teeth) Grinding ha-itsA an erosive diet or alcohol consumptions are also relevant) Past Dental 6istor Present Past dental !istor

*eveals information a-out past dental pro-lems and treatment) If a patient has difficult tolerating certain t pes of procedures or has encountered pro-lems (ith previous dental careA an alteration of the treatment or environment ma help avoid future complications) Also important to #no( the date and t pe of availa-le radiographs to ascertain the need for additional radiographs and minimi@e the patients e,posure to radiation) Present dental !istor The most common complaint that leads to dental treatments is pain or s(elling) 5uestions li#e (hen did ou first notice this (Inception)A factors that improve or (orsen the condition (Provo#ing factors)) /actors that relieve the pain host or cold (attenuating factors)) (/re8uenc ) of pain (Intensit ) of pain is mildA moderate or severe) (locali@ed or referred) location of pain (Duration) of painA momentar or long lasting (Postural) pain is (hen ou -end or lie do(n) (Stimulated or spontaneous) pain) % (7"alit 8 of pain is sharpA lancinatingA sta--ingA dull or thro--ingA gro(ing)

Treatment Diagnosis &onsult *eferral Data +valuation *adiographic Interpretation Diagnostic Tests Medical 'istor Dental 'istor Ph sical Inspection Patient Interaction

&hief complaint
* Ris+ Assess%ent % % % Patient should me made a(are of their ris# status) This #no(ledge encourages them to #eep appropriate recall appointments and to -ecome involved in their o(n preventive care) A cluster anal sis model for caries ris# assessment (as applied to determineA the natural grouping of individuals among si,t :%1= ear old children and to identif the most significant set of mar#ers for ris# assessment) % *is# clusters (ere o-tained (ith initial clinical and -acteriological measurements including DM/ H DM/SA active cariesA mutans streptococci and lacto-acillus counts in pla8ue or saliva and s nderi test) % This set of mar#ers identified :7I of children at high ris# and <!I of children in lo( ris# cluster) Sanc!e95Pere9l et al :Arc! oral ;iol$2<<4= Se)t$ 4>:>8 ?1>52@8 CARIES RISA ASSESSMENT 6ig! ris+ Low Ris+ Social 6istor Sociall deprived Middle class 'igh caries in si-lings 6o(er disease Irregular attendance *ead availa-ilit of snac#s 6o( dental aspirations #no(ledge of dental 6o( caries in si-lings Dentall a(are *egular attendance "or# does not allo( regular snac#s)

'igh dental aspirations Medical 6istor Medicall compromised Go medical pro-lem 'andicapped >erostomia Go ph sical pro-lem Gormal salivar flo(

6ong term cariogenic medicine Go long term medication Dietar !a(its /re8uent sugar inta#e Infre8uent sugar inta#e Bl"oride "se

 Gon%fluoride area Go fluoride tooth paste

/luoridation area

/luoride tooth paste used PlaC"e control Infre8uentA ineffective cleaning /re8uentA effective cleaning Poor manual control Sali,a 6o( flo( rate Gormal flo( rate Clinical E,idence Go ne( lesions Gil e,traction for caries Sound anterior teeth Go or ne( restorations *estorations inserted ear age) Go appliances Good manual control

Ge( lesion s Premature e,tractions

Anterior caries or restorations Multiple restorations 'istor of repeated restorations Partial dentures $ E*a%ination and diagnosis E*tra oral e*a%ination General EuiltA gait 6ocal % % % % % % %

Should -egin (hile clinician is ta#ing patients dental histor - o-serving the patients facial features) 6oo# for facial as mmetr or distension that might indicate s(elling of odontogenic origin or s stemic ailment) Patients e e for papillar dilation or constriction that ma indicate s stemic diseaseA premedication or fear) 6ips %J competent or incompetent) Patients s#in for an lesions (S)A if more than oneA (hether lesions appear at random or follo( neural path(a ) +,amination of su- mandi-ular glands su-%mental and cervical nodes) /or a-normalities in si@eA te,tureA mo-ilit and sensitivit to palpaton (Eimanual palpation)) Masticator muscles for pain or tendernessA e,amination of TMK deviationA clic#ingA tenderness) Vital signs

 ;lood Press"re / Gormal

13=F:= mm 'g for -elo( 7= ears) 1!=F<= mg 'g a-ove 7= rs)

It must -e stressed that no patient (ith or (ithout a dental emergenc A should -e treated (hen his diastolic E)P) is over 1== mm 'g) % % % % P"lse Rate and Res)iration / Gormal : Pulse : 7=%1== Fminute) *espiration : 17%1:Fminute Temperature : Gormal -od temperature : 49o&) <:)7 o/) An elevated -od temperature is one indication of total -od reaction to inflammator disease) A temperature a-ove <:)7 of -ut less than 1== o/ indicates locali@ed disease (Summers G)") 1<97)) Intra oral e*a%ination So&t tiss"e 2isual e,amination and palpation of -uccal muocsa -uccal vesti-ulesA hard palateA soft palateA lipsA tonsillar areasA tongue and floor of the mouth) % 6ard tiss"e % C!arting and Records / &harting s stem includes identification dataA medical histor A dental histor A clinical e,aminationA diagnosisA treatments planning documentation or informed consentA progress notes and completion notes) % &harting s stem is necessar for man reasons including : * Proper care $ 5ualit assessment $ 6egal proceedings $ /orensic uses) % Toot! Denotation s ste% Pal%er s ste% 5 common in ;)L) : %1 1%: : %1 1%: Designated as 7 Letter code 5 DR DL LR LL

5 International (/DI) % 1 !

Designated as ;6 7

/ederation Dentaire common in +urope 3 4

% Designated as 37 ;niversal &ommon in ;)S)A) % 1 17 43 19 % Designated as 1! * Clinical e*a%ination o& caries The pre re8uisites for caries diagnosis are :% Good lighting &lean teeth A three in one s ringe so that teeth can -e vie(ed -oth (et and dr ) Sharp e es (ith vision aided - magnification *eproduci-le -ite(ing radiographs E*a%ination o& caries on occl"sal s"r&aces % % &aries is most prevalent in fault pits F fissures of occlusal surfaces (here developmental lo-es of posterior teeth foiled to coalesce partiall or completel ) .cclusal surface is diagnosed as diseased if an one of the findings is present) &hal#iness or softening of the tooth structure forming the fissure F pit) Ero(n gre discoloration radiating peripherall from the fissure F pit) *adiolucenc -eneath the occlusal enamel surface % % % % Active uncavitated lesion is (hiteA often (ith a mar# surface) &orresponding inactive lesion ma -e -ro(n) These enamel lesions are not visi-le on a -ite(ing radiograph) +namel lesion that is onl visi-le on a dr tooth surface is in the outer enamel)

% % % % %

6esion visi-le on a (et surface is all the (a through the enamel and ma -e into dentine) &avitated lesions present as micro cavities (ith or (ithout gra ish discoloration of enamel A lesion missed on visual e,amination -ut found on radiograph % C'idden cariesB) Difficult to see a carious enamel lesion as the form Dust cervical to contact area and vision o-scured - adDacent tooth) Eecause if lesion is discovered clinicall A it is usuall at a relative late stage (hen it has progressed (ell into dentine and seen as pin#ish gre area shinning up through marginal ridge)

E*a%ination o& caries on )ro*i%al s"r&aces$

% % % %

Eite(ing radiographs important in diagnosing appro,imal caries in -oth enamel and dentine And once lesion is visi-le in enamel on -ite(ing radiograph it is usuall in dentine (hen e,amined histologicall Appro,imal enamel lesion appears as dar# triangular area in enamel on a radiographA ape, to(ards the enamel dentine Dunction) &aries on appro,imal root surface is visi-le on -ite(ing radiographM sometimes it is confused (ith a cervical radio lucenc or C-urnoutB) This is a perfectl normal appearance at the gap -et(een dense enamel over cro(n of the tooth and crest of alveolar ridge (here ,%ra pass tangentiall through dentine of root (not through enamel or -one) giving a relativel radio lucent appearance)

% %

Transmitted light used in diagnosis of appro,imal caries in anterior teeth) In posterior teethA a stronger light source is re8uired and fi-re optic lights (ith -eam reduced to =)0 mm diameter have -een used)

* E*a%ination o& root s"r&ace caries % % % ;ncavitatedA active lesions are close to gingival margin and have %ar+ s"r&ace$ Inactive lesions are further from the gingival marginA (hite or -ro(n in color (ith a shin surface) Active lesions are softA pla8ue covered arrested lesions are hard and pla8ue free)

Incipient caries on facial and lingual smooth surfaces appear as (hite spot (hich (ill partiall or totall disappear) /rom vision on (etting) Dr ing again (ill cause it to reappear)

This disappearing reappearing phenomenon helps to distinguish -et(een smooth surface incipient caries and non%hereditar enamel h pocalcification (Does not disappear on (etting))

Clinical e*a%ination o& additional de&ects Toot! wear C!e%ical erosion/ is the loss of surface tooth structure - chemical action in the continued presence of deminerali@ing agent (Acid)) Res"lting de&ecti,e surface is smooth E*ogeno"s acidic agents such as gastric fluids cause generali@ed erosion of lingualA incisal and occlusal surfaces) Idio)at!ic erosion 5 cervical (edge shaped defect (angular)A predominant causative factor is heav force is eccentric occlusion resulting in fle,uring of the tooth) This tensile stress in the effected (edge shaped region on the tooth side a(a from the tooth -ending directionA results in loss of surface tooth structure ter%ed #a(&raction.$ A(rasion/ is a-normal tooth surface loss resulting from direct frictional forces -et(een the teeth and e,ternal o-DectsA or from frictional forces -et(een contacting teeth in the presence of an a-rasive medium) Seen as a sharp (edge shaped notch in the gingival portion of facial aspect of teethA surface of defect is smooth) ;suall caused - improper -rushing techni8ues Present on such defects does not automaticall (arrant interventionA rather it is important to determine and eliminate the cause) Attrition Is mechanical (ear of incisal or occlusal tooth structure as a result of functional or parafunctional movements of the mandi-le) Micro &ract"re

&ertain degree of attrition is e,pected (ith agingA -ut in case of a significant a-normal attritionA the patients functional movement must -e evaluated and en8uiring made a-out an ha-its creating this pro-lem such as tooth grinding or -ru,ism usuall due to stress)

De,elo)%ental de&ects % Ac8uired % 'ereditar

AcC"ired 1$ Ena%el ! )o)lasia and 6 )o%inerali9ation % % 6 )o)lastic ena%el results from production of reduced amount of matri, (hich natures normall A -ecause enamel is pitted or thin -ut of normal hardness) 6 )o%inerali9ed ena%el results (hen normal amount of matri, fails to achieve full minerali@ation) Affected enamel has normal shape and thic#ness -ut has opa8ue chal# (hite appearance) % % MaDorit of s stemic distur-ances last onl a fe( (ee#s and -ecause the defect ta#es the form of narro( hori@ontal -and around affected cro(n and cro(ns ' pominerali@ation affecting occlusal surfaces appear (hite ello( or ello( -ro(n opacities that chip off easil leading to unprotected dentineA pla8ue stagnation and rapid caries development) 2$ Dental Bl"orosis % % .ccurs (hen total dail inta#e of fluoride ion is high (hile the enamel is undergoing pre eruption formation and maturation) Appears as chal# (hite flec#s or confluent -lotches and -ro(n discoloration sometimes accompanied - pitting of enamel 3$ Tetrac cline staining % .ccurs (hen drug is ta#en - infants and oung children or pregnant (omen (here in the developing permanent teeth are affected sho(ing hori@ontal -and of discoloration) 6ereditar conditions 1$ 6 )odontio= %icrodontia %J teeth a-normal is shape or si@e)

;pper lateral incisorsA upper and lo(er second premolars and third molars most commonl affected)

2$ A%elogenesis i%)er&ecta/ 5 Two di&&erent )atters a) -) Generali@ed h poplasia : defect in enamel matri, formationA appear ello( (ith thin enamel or granular or pitted enamel surfaced (hich ma pic# up stain) Generali@ed h pominerali@ation : incomplete minerali@ation of normal matri,) +namel ma appear stained and dar#ened or dull and chal# (hite) 3$ Dentinogenesis i%)er&ecta / deficient formation of dentin and is characteri@ed - -ro(n opalescent discoloration of teeth (hich are prone to earl fracture and e,cessive (ear) * E*a%ination o& tra"%a % % % % % % % &ro(ns of the teeth e,amined for fractureA pulp e,posure and color changes) Displacement or looseness of teeth should -e noted) &hec# for a-normalities of the occlusion) 2italit of the inDured and adDacent teeth must -e tested) Periapical radiographs ta#en to loo# for root fracture) "here fractures of ma,illa or mandi-le are suspectedA further radiographs of facial s#eleton re8uired) At su-se8uent recall visits the color of the tooth and further vitalit tests and periapical radiographs (ill sho( (hether pulp has remained vital or not) * E*a%ination o& a%alga% restorations % Amalgam restorations are evaluated for Amalgam -lues Pro,imal overhange) Marginal gap or ditching) 2oids /racture lines Interface lines Improper anatomical contours)

 Marginal ridge incompati-ilit Improper pro,imal contacts *ecurrent caries)

E*a%ination o& cast restorations % % Is evaluated clinicall in the same manner as amalgam restorations) If restorations are not satisfactor or carr ing tissue harm it is classified as defective and considered) /or recontouringA repair or replacement) E*a%ination o& toot! colored restorations An improper pro,imal contactA contourA overhanging pro,imal marginA recurrent caries then the restoration is considered defective) If dar# marginal staining or discoloration presentA estheticall displacing then replacement) E*a%ination o& Periodonti"% Clinical e*a%ination % % % % % Gingival color and te,ture is e,amined as the are important indices of periodontal health) Depth of gingival sulcus around each tooth is determined) Presence of poc#et (Sulcus depth greater than 4mm) or haemorrhage or e,udates indicates periodontal disease) +valuate presence of -ifurcation or trifurcation involvement affects long term prognosis of the tooth) Gote areas of gingival recession Teeth should -e evaluated for mo-ilit %J as it indicates significant loss of -one support (hich could affect su-se8uent operative treatment) Radiogra)!ic e*a%ination % % Eite(ing radiographs help in assessing -one levels) *adiographs aid in determining the relationship -et(een the margins of e,isting or proposed restorations and the -one) E*a%ination o& occl"sion

The static relationship of the teeth in intercuspal position (I&P) should -e e,amined to determine the hori@ontal and vertical overlap of the anterior teethA together (ith the relationship of posterior teeth)

The (a in (hich the teethA function against each other in for(ardsA -ac#(ards and lateral movement of the mandi-le should -e e,amined) +,amination should also loo# for CPlunger cuspB (hich is a pointed cusp plunging deep into the occlusal plane of the opposing arch) This ma result in food impaction or toothFrestoration fracture)

E*a%ination o& )ain :Toot! ac!e8 Bield defined pain as Can unpleasant sensation that is perceived as arising from a specific region of the -od and is commonl produced - processes that damage or are capa-le of damaging -odil tissueB) International Association &or t!e st"d o& )ain :IASP8 defined pain as CAn unpleasant sensor and emotional e,perience associated (ith actual or potential tissue damageA or descri-ed in terms of such damageB) P"l) )ain/ or pulpalgiaA is the most commonl e,perienced pain in and near the oral cavit and ma -e classified according to degree of severit and the pathologic process present : 1$ 6 )er reacti,e )"l)algia$ a) Dentinal h persensitivit -) ' peremia 2$ Ac"te P"l)algia$ a) Incipient -) Moderate c) Advanced 3$ C!ronic P"l)algia a) Earodontalgia 4$ 6 )er)lastic )"l)itis @$ Necrotic )"l) E$ Internal resor)tion ?$ Tra"%atic Occl"sion F$ Inco%)lete &ract"re

Mildest pulp discomfortA e,perienced (hen no inflammation is presentM is h per reactive pulpalgia 7"alit o& )ain/ Pulp pain are of t(o varieties a$ S!ar)= )iercing an lancinating a painful response associated (ith e,citation of the A%delta fi-res (M elinatedA post conducting and lo( pain threshold) &old stimulates the fast conducting as fi-res This pain usuall reflects reversi-le state) ($ D"ll= (oring= gnawing and e*tr"ciating 5 a painful response usuall associated (ith &% nerve fi-res (;nm elinatedA slo( conducting and higher pain threshold)) pulpitis) Pulpal and periapical pathosis produce sensations that are descri-ed (ith terms such as % % % % % % % Aching Pulsing *adiating /lashing Nolting +lectric *ecurrent 'eat usuall stimulates the slo( conducting (/i-res $ This pain usuall reflects an irreversi-le state of

D"ration o& )ain % % Pain of shorter durationA is considered to -e reversi-le pulpitisA (hereas (hen pain is of longer duration irreversi-l ) Tooth (ith pulpal pain that disappears on removal of irritant has sho(n e,cellent chance of recover (ithout the need of endodontic treatment) Ince)tion 1$ Mode / Spontaneous or provo#edA sudden or gradualA stimulated * Immediate $ Dela ed

2$ Periodicit / S mptoms have temporal pattern or sporadic or occlusionalA recurrent pain) 3$ BreC"enc / &ontinuous or Intermittant) Intensit o& )ain 1) 3) 5uantif the pain - assigning to the pain a degree of = (none) to 1= (intolera-le pain) helps to monitor patrents perception of pain throughout the treatment) MildA moderate or severe)

Predis)osing &actors % % % % /actors that can precipitate the onset of s mptoms (hich ma indicate a non%odontogenic cause) Post"ral c!anges / Ka( pain or headache on -onding overA -lo(ing the nose or Dogging %J ma,illar sinusitis Ti%e o& da 5 sti&&ness and pain in Da(s and masticator muscles a (a#ing TMK d sfunction) Pain on strenuous or vigorous activit %J pulpal or periapical inflammation) 6or%onal c!ange CMenstrual tooth acheB or recurring h persensitivit ma occur due to increased -od fluid retention) S mptom disappears (hen the c cle ends) Re&erred )ain &ommon in advanced pulpitis) Posterior molar pain often referred to opposing 8uadrant) Ma,illar molars to %J @ gomaticA parietal and occipital regions of the head) 6o(er molars to %J earA angle of the Da( or posterior region of the nec#) 6ocali@ation of pain Sharp piercing pain can usuall -e locali@ed and responds to cold) Dull pain usuall referred F spread over a large area responds more a-normall to heat) Patient ma report dental pain that is e,acer-ated (hile l ing do(n or -ending over) This occurs -ecause of increase in -lood pressure to the headA (hich su-se8uentl increases the pressure on the confined pulp) Bactors w!ic! )ro,o+e :relie,e )ain8 :IEG= 1>>< ( A6$ Rowe et al8 % .n assessment of pulp vitalit - A)') *o(e et alA response to a provo#ing factor (+)g) on mastication) indicates pulp vitalit A -ut stimulation causing e,tended severe pain suggests irreversi-le pulpitis)

'eatA coldA s(eetsA percussionA -itingA che(ingA palpation)

Diagnosing toot!ac!e$ A patient complaining of toothache is most li#el follo(ing conditions) Acute Pulpitis Acute apical periodontitis Acute apical a-scess Acute periodontal a-scess &hronic pulpitis &hronic apical periodontitis +,posed sensitive dentin) /ood pac#ing &rac#ed cusp Pulpitis resulting from caries is most common cause of tooth ache) Several other conditions of mouth and face ma -e confused (ith tooth ache) +,ample : Ma,illar sinusitis) $ Pericoronitis $ Trigeminal neuralgia Mandi-ular d sfunction At pial facial pain 6esions of salivar glands and soft tissue) Ac"te )"l)itis Severe painA poorl locali@ed to the tooth T(o clinical presentations $ *eversi-le $ Irreversi-le Differential diagnosis of reversi-le and irreversi-le pulpitis) Re,ersi(le Irre,ersi(le to -e suffering from one of the

1$ 6istor 3) Pain

Slightl

sensitivit

or &onstant or intermittent dela ed

occasional pain pain Momentar and immediateA &ontinuousA sharp in nature and 8uic#l

onsetA thro--ingA persists)

dissipates after removal of /or minutes to hours after 4) 6ocation of pain stimulus) removal of stimulus Ma -e locali@ed and not Pain not locali@ed referred locali@ed peripheral !) &hange of posture 0) Thermal test 7) +)P)T 9) Percussion Go difference *esponds +arl response Gegative onl it

after

involvement)

Pain is re&eH$$ Pain increases Mar#ed prolonged) +arl A dela ed or mi,ed response Gegative in earl later positive stages (hen

:) *adiograph

Gegative

periape, involved) Ma sho( (idening of periodontal space) ligament

Ac"te a)ical Periodontitis &lassical presenting sign is that patient presenting indicating (hich tooth is causing painA (hereas patient (ith acute pulpitis holds their hand to the side of their face) Tenderness on percussion Pulp contains pain nerve endings onl -ut the periodontal ligament contains -oth pain and pressure sensitive nerve endings) Ac"te a)ical a(scess Patient presents (ith a large tender s(ellingA either intra orall or on the face) Sometimes patient presents -efore s(elling has appeared or after it has spontaneousl -urst or su-sided) Patient ma feel un(ell and have a temperature) Pulp usuall gives a non vital response)

Ac"te Periodontal a(scess /orms at the -ase of deep periodontal poc#etA presentation similar to acute apical periodontitis or acute apical a-scess -ut tooth ma still -e vital) In some cases infection arising from deep poc#et meets (ith infection arising from necrotic pulp %Jperio %J endo lesion (Poor prognosis))

C!ronic P"l)itis Produced mildA poorl locali@ed pain (hich sometimes comes and goes over a period of (ee#s or months) If untreatedA pulp -ecomes non%vital and s mptoms of chronic pulpitis disappears *esponds to vitalit test) Got tender or percussion

C!ronic a)ical )eriodontitis$ S mptomless conditionA ma feel mild pain on -iting) 2italit test negative) Slightl tender to percussion (Dull note) Main diagnostic sign % is peri apical radio lucenc seen) "hen sinus is present % gutta percha point (ill sho( approaching the ape, of the relevant tooth on the radiograph) In all a-ove conditionA no radiographic changes in periapical tissues e,cept a slight thic#ening of apical periodontal space (ith acute apical a-scess) In chronic stateA apical granuloma not infected %J chronic inflammator response to to,ins leaching from ape, of tooth (ith necrotic pulp) These to,ins are diluted -ecause natural limit to si@e of chronic periapical granuloma Ee ond this si@eA to,ins are too dilute to stimulate osteoclastic action) A peripheral granulomaA highl vasculari@ed repair tissueA -ecause after root canal therap granuloma replaced - normal -one) &hronic apical granuloma

Ma -ecome infected And flare up into an Acute apical a-scess (Phoeni, a-scess) E*)osed sensiti,e dentin Ma

or ma -ecome c sticA (hich also can -ecome infected and flare up into A)A)A)

result from gingival recession or surger

producing e,posed root surfacesA

failing restoration or caries e,posing dentine to oral fluids) Sensitivit to hotA cold) S(eet) /ood ? drin#) Poorl locali@ed

Bood )ac+ing &ontact point not tight due to teeth drifting apartA poorl contoured restoration) /ood (edges -et(een the teeth and causes periodontal pain) DIAGNOSTIC AIDS IN CARIES The coronal carious lesion starts as a clinical undetecta-le su- surface deminerali@ation (ith further progressionA it (ill eventuall -ecome clinicall detecta-le) Apart fromA for the occult fissure penetrating deepl into the dentinA dilemmas in clinical detection and registration arise not (ith the advanced lesionA -ut primaril (ith the earl lesion (confined to out enamel)A the non%cavitated lesion of dentinA recurrent caries (around the margins of restoration) and su- gingival root caries) According to Pitts (1<<9)A the ideal method or toot for diagnosis of carious lesions (ould -e non%invasive and provide simpleA relia-leA validA sensitiveA specific and ro-ust measurements of lesion si@e and activit and -e -ased on -iologic processes directl related to the carious process) Diagnostic tools$ Some decades agoA visual diagnosis (light and mirror) and pro-ingA supplemented - -ite(ing radiographs (ere the onl roots availa-le for clinical diagnosis of caries) These tools detected the presence of cavitation rather than measuring the disease as a continuous process that starts from the appearance of microporosit as a result of deminerali@ation leading to cavitation)

The radiographic image of occlusal fissure is comple, and is such that caries (ould onl -e visi-le (hen it affects the -ase of the fissure) .cclusal caries progresses along the fissure (allsA finall reaches dentin) Old trends 1$ Vis"al detection &om-ination of light and minor Most commonl applied method Sensitivit is lo(A specificit high MaDor shortcoming is that this method is ver limited for detecting non%cavitated lesions in dentin on the posterior appro,imal and occlusal surface) 2$ Tactile sensation wit! e*)lorers &aries is diagnosed if tooth meets the ADA criteria of softened enamel that catches an e,plorer and resists its removal or allo(s the e,plorer to penetrate pro,imal surface under moderate to firm pro-ing pressure) In recent earsA it has -een sho(n that a sharp e,plorer ma cause cavitation of an intact surface enamel (ith su- surface deminerali@ation (Eergnan and 6inden 1<7<A 5uist and Th lstrup 1<:9) and could force cariogenic -acteria into depth of lesion) 3$ Radiogra)!s Eite(ing and periapical radiographs commonl used) Also occlusal radiographsA panoramic radiographs are sometimes indicated The diagnostic ield that could -e gained from a radiograph out(eighs the potential adverse effects of e,posure to radiation) *adio graphs have some limitations 3 dimensional representation of 4 % dimensions o-Dect) Interpretation (ould produce certain false % positive and false negative diagnosis Does not diagnose earliest stages of lesion) Appro,imal caries (secondar ) on more apical part of restoration ma not -e detected) Gon cavitation carious lesion on the root are difficult to diagnosis)

 The onl (a to guard against these limitations is to continuall correlated clinical and radiographic findings) 4$ Te%)orar electi,e toot! se)aration and i%)ression ;sing (edges and elastics 'elps in assessing (hether radiographicall detecta-le appro,imal enamel and dentin lesions are cavitated) &om-ined (ith locali@ed impression allo(s a more sensitive diagnosis of cavitation)

@$ Caries detector d es$ 2an de *iD#e (1<<1) revie(ed the use of d es in cariolog ;sed clinicall to differentiate -et(een outer carious dentin and inner affected dentin .uter carious dentin is distinctl stained) /luorescent % /luoros TGA % sodium fluorescent N glo 31%33A p rromethene 007) Gon fluorescent % 1I acid red in prop lene gl col % &arsolen green % 6ssamine -lue 1I acid red is -asicall a food d e) Iodide penetration method for measuring enamel porosit of incipient smooth surface lesion (as developed - Erudevold and co%(or#ers) Newer trends 1$ Co%)"ter - ;ased i%age anal sis *ecentl -een applied for e,amination of dental radiographs) Program detects a lesionA and designs its -ordersA measures and reports the lesions parametersA percent minerali@ation area and ma,imal and mean enamel penetration) 2$ 7"antitati,e lig!t ind"ced &l"orescence :7LIB8

Eenedict (1<3:) first noted fluorescence of organic components of teeth and also the difference in fluorescence -et(een sound and carious enamel using visi-le light compared (ith ultra violet light 6esion (ith depth of onl 30 um have -een measured) Deminerali@ed area appears as dar# region -ecause of loss of intrinsic fluorescence su-stances (h dro, apatite cr stals and tu-ules) in deminerali@ed enamel and dentin) 5uantitative laser induced fluorescence used organ ion laser (!:: mm)) In some studiesA fluorescence d e (as applied to the lesion to enhance the difference -et(een sound and carious tissues) &urrentl 56/ s stem uses are lamp filtered to a small -and (49= H := nm) ;ses -ecause +arl caries detection Monitoring (hite spot lesion +valuation of 8ualit of fissure sealants and dental restorations (red fluorescence indicates micro lea#age porph rins meta-oli@ed - -acteria) Detection of pla8ue Li%itations *estricted to smooth surface caries diagnosis) Should -e performed under standardi@ed conditions regarding h dration of tooth &ircular lesion (Mesio-uccal or disto-uccal) cannot -e detected -ecause optical a,is of 56I/ has to -e oriented Ist molar to tooth surface 3$ Electro cond"ctance %eas"re%ent :ECM8 Idea of electrical method of caries detection first proposed - Magitot (1:9:)) Theor : Sound surfaces posses limited or no conductivit A (hereas carious or deminerali@ation enamel have measura-le conductivit that increases (ith increasing deminerali@ation) Pincus (1<01) first suggested the concept of testing for caries through electrical inde)endence) Su-se8uentl t(o instruments (ere developed in 1<:=) 1) 2anguard electronic caries detector 3) &aries meter 6

Eoth instruments measured the electrical conductance -et(een the tip of a pro-e placed in the fissure and a connector attached to an area of high conductivit (e,ample gingiva and s#in)) In vanguard +&DA the recording dial sho(s num-er =%1= and a picture of a CfaceB that smiles up COOO)B to value of 0 (caries ve) and fro(ns COOO))B (hen the value is greater than 0 (&aries Hve) A ne( instrument electronic caries monitor is currentl -eing evaluated) 4$ Digital &i(re o)tic trans%ill"%ination :DIBOTI8 Illumination is delivered - means of fi-re optics from a light source to tooth surface) *esultant changes in light distri-ution as light transverses the tooth are recorded as image for anal sis) /.TI: designed for detection of pro,imal caries (/riedman and MarcusA 1<9=)) Deca ed tooth material sca##ers light more strongl A thus has lo(er inde, of light transmission than sound tooth structure) DI/.TI - com-ining /.TI and digital &&D camera) DI/.TI can detect incipient and recurring caries -efore the are visi-le on radiographs) @$ Endosco)ic &iltered &l"orescence :EBB8 +ndoscopic e,amination (ith either (hite light or filtered fluorescence e,cited - -lue cutting light (as performed - long -ottom and Pitts (1<<=) Their studies sho(ed that (ith -oth methods initial pro,imal lesions appear dar#er than surrounding areas) E$ Alternating c"rrent in)edence s)ectrosco) tec!niC"e :ACIST8 A more sophisticated approach to lesion detection and measurement is to characteri@e the electrical properties of the tooth and lesion fre8uencies) The A&IST is ne( and has -een evaluated onl to a limited e,tent on (hole carious teeth) ?$ Magnetic resonance %icro i%aging :MRM8 Significant value in detection of earl changes in minerali@ed dental tissue) Gon invasive and non destructive using A&IST (hich scans multiple

Its use allo(s a specimen to -e reimaged after further e,posure to a clinicall allo(ed orientationA if these orientations are pertur-ed energ is a-sor-ed and then retransmitted) It is this retransmitted energ that is detected) F$ Dltra sonic I%aging

relevant

environment) "hen a magnetic field is appliedA the nuclear spins align in a finite num-er of a pulse of radiofre8uenc energ A this

;ltrasonic imaging (as introduced - Ggo et al (1<::) as a method for detecting earl caries in smooth surface) The sho(ed (in vitro) that artificial enamel lesions less than 09I of sound enamel mineral content in the -od of the lesion could -e differentiated acousticall from intact enamel on the -asis of amplitude changes) The authors concludedA ho(everA that the method is not et sensitive enough to detect changes of shallo( caries lesions in vivo) >$ DIAGNODENT$ Tooth surface is illuminated (ith pulses of red laser lightA and fluorescence emitted from the surface is anal @ed and 8ualified) &aries lesions alter the amount of fluorescence that can -e seen as increased needing) A valua-le adDunct for occlusal caries detection in permanent teeth (6ussi et al 1<<<) &ommercial development is chairsideA -atteria po(ered Diode laser fluorescence device) This unit emits light at 700 non (ave length from fi-re optic -undle directed onto occlusal surface) A second fi-re optic -undle receives the reflected fluorescence light -eam and changes caused - deminerali@ation are displa ed as numerical value on the monitor) A laser pro-e is used to scan over the fissure area in s(eeping motion) Gumerical value $ 0 30 indicate initial lesion in enamel $ Greater than 30 earl dentinal caries $ Greater than 40 advanced caries) 5 Li%itations Depth of penetration of light limit to 3 mm) Detects onl occlusal involvement not appro,imal surfaces)

1<$ Stra - Bield I%aging :STRABI8 is a magnetic resonance microscopeA that sho(s outer and inner contours of the teeth) The resolution in M* imaging is provided - change of magnetic field) A non destructive (a to e,amine root canal morpholog )

11$ Radio Vis"ogra)! :RVG8 Digiti@es ioni@ing radiation and provides an instantaneous image on a video monitor there- reducing radiation e,posure - :=I) 'as a fi-re optic intra oral sensor) Advantages +limination of ,%ra sensor) Significant reduction in e,posure time Instantaneous image displa ) 'as 4 components 1) 3) 4) #Radio. a h persensitive intra oral sensor and a conventional ,%ra unit) #Visio. consists of video monitor and displa processing unit) #Gra)! . component high resolution video printer that instantl provides a hard cop of screen image) *esolution is slightl lo(er then conventional filmsA ho(ever can -e improved through enhancement procedures) 12$ Caries acti,it tests 'elps in identif ing high ris# groups and individuals) Introduced - 'adle in 1<44A populari@ed - Da ) Go of lacto-acillus colonies in saliva are related to caries suscepti-ilit 3) &olorimetric Sn der test Measures the a-ilit of salivar m)o) to form organic acids from a &'. mediumA (hich contains indicator d eA Eromoc es of green) *ate of color change from green to ello( is indicative of the degree of caries activit ) 1) 6acto-acillus colon count tests

4) S(a- test Developed - Grainger 1<70) S(a- is incu-ated in the medium for !: hrsA change in p' is indicative of degree of caries activit ) !) Salivar Euffer capacit ) 2olatile -icar-onate onion is the important component of salivar -uffer s stem) Saliva samples re8uiring less than =)!0 ml of standard 'cl have lo( -uffer capacit and those re8uiring =)!0 ml or more have high -uffer capacit ) 0) Streptococcus mutans level in saliva) Measures the num-er of streptococcus mutan colon forming units per unit volume of saliva) 7) +namel solu-ilit test Glucose is added to saliva containing po(dered enamel) Thus organic acids are formedA (hich decalcif the enamelA resulting in increase in solu-le calcium (hich is a direct measure of degree of caries suscepti-ilit 9) Salivar reducta-le test Measures the activit of reducta-le en@ me present in salivar -acteria) :) Al-an Test Simplified form of S nder Test Meas"re%ent o& sali,ar &low rate +as to measure at the chair side) Patient che(s paraffin (a, to stimulate saliva for 1 min and spits it into a measuring c linder) Stimulated salivar flo( rate a e,pressed in milli litres (ml) per minute) Gormal rate in adults P 1%3 mlFmin) >erostomia P =)9 % =)1 ml F min) DIAGNOSTIC AIDS IN ENDODONTICS 1$ Vis"al and Tactile ins)ections +,amination of hard (ith soft tissue for 4 &Qs : &olorA contour and consistenc

 Soft tissue Color/ Gormal color of gingiva is pin#A change from this is easil visuali@ed in inflammator conditions) Conto"r/ change in normal contour (Scalloped gingiva) occurs (ith a s(elling) Consistenc / on inspection (gingiva) appears healthA firmA resilientA (hile a softA fluctuant or spong tissue is move indicative of a pathological state) 6ard tiss"e Color/ Gormal teeth sho( life li#e translucenc and spar#le that is missing in pulpless teeth (hich appear more or less opa8ue) Conto"r/ e,amination of contours of effected teethA such as fractured teethA (ear facetsA improperl contoured restorations or altered cro(n contours as these factors can have mar#ed effect on the respective pulps) Consistenc / change in consistenc is related to presence of cariesA e,ternal and internal resorption) % Presence of sinus tract opening into gingival crevice and deep poc#ets are discovered tracing (ith a gutta percha cone) 2$ Pal)ation Simple test done (ith finger tip using light pressure to e,amine tissue consistenc and pain response) 'elps to determine the follo(ing a) -) c) d) "hether tissue is fluctuant and enlarged sufficientl for incision and drainage) PresenceA intensit and location of pain) Presence and location of edenopath Presence of -one crepitus) l mph nodes are usuall involvedA anti teeth su-mental l mph nodes involved) "hen infection confined to pulp and not progressed into periodontium palpation is not diagnostic) PalpationA percussionA mo-ilit and depressa-ilit test chec# the integrit of attachment apparatus and not the condition of pulp) 3$ Perc"ssion

"hen posterior teeth are infectedA su- ma,illar

 Tooth is struc# (ith a 8uic#A moderate -lo( initiall (ith lo( intensit - the fingerA then (ith increasing intensit - the fingerA then (ith increasing intensit - using handle of an instruments) A positive response to percussion indicates not onl the presence of inflammation of periodontal ligament -ut also the degree of inflammation) Periodontitis can also occur around tooth (ith vital pulp as in rapid ortho movementA recentl placed restoration in h per occlusion) &hronic peri apical inflammation often ields negative result (ith percussion) Dull note signifies a-scess formation Sharp note denotes inflammation (Ingle) 4$ Mo(ilit and de)ressa(ilit tests *ationale of mo-ilit test is to evaluate the integrit of the attachment apparatus surrounding the tooth) Test consists of moving the involved tooth facio%linguall using handles of t(o instruments or using t(o inde, fingers) Test for depressi-ilit is performed - appl ing pressure in an apical direction on the occlusalFincisal aspect of tooth and o-serving vertical movement if an ) "hen this e,ists chances for retaining the tooth ranges from poor to hopeless) Grades of mo-ilit (Grossman ? &ohen) Grade I (/irst degree) % 6ess than 1 mm of hori@ontal movement) Grade II (Second degree) 6ateral ('ori@ontal) movement of around 1 mm) Grade III (Third degree ) greater than l mm of hori@ontal movement accompanied - vertical depressa-ilit Grades o& %o(ilit :%iller8 = 1 3 4 % % % % Gon mo-ile F mo-ilit (ithin ph siological limits Mo-ilit (ithin range of = =)0 mm mo-ilit (ith =)0 1)0 mm (ith lateral movements) Mo-ilit more than 1)0 mm (ith lateral movements and can -e depressed

into the soc#et

 +ndo treatment should not -e carried out on teeth (ith third degree mo-ilit unless mo-ilit is reduced - drainage of acute apical a-scess) Mo(ilo%eters are electronic devices F gad getsA (hich aid in determining tooth mo-ilit Apparatus consists of t(o electrodes (Pra s (hich hold facial and lingual surface of the teeth) Degree of mo-ilit tested is reflected as a numerical reading) @$ Periodontal e*a%ination &onsists use of a -lunt celi-rated pro-e to e,plore the integrit of gingival sulcus around each tooth) A significant poc#et if present in the a-sence of periodontal disease it increases the pro-a-ilit of presence of vertical treatment) To distinguish disease of periodontal origin from pulp originA thermal and +PT along (ith PD6 pro-ing are essential)

E$ Radiogra)!ic e*a%ination *adiograph is 3 dimensional image of 4 dimensional tooth -ecause radiographic strateg should involve the e,posure of 3 films at the some vertical angulation -ut (ith 1=%10 degree change in hori@ontal angulation (S6.E rule) Radiogra)!s can contain in&or%ation on 1$ Presence of caries that ma involve or threat on to involve the pulp) 2$ Ma sho( the num-erA causeA sharp length and (idth of root canals) 3$ Presence of calcified materials in the pulp cham-er or root canals) 4$ *esorption of dentin originating (ith in the root canal or from the root surface) @$ &alcification or o-literation of pulp cavit E$ Thic#ening of PD6 ?$ *esorption of cementum F$ Gature and e,tent of periapical and alveolar -one destruction)

Radiogra)!ic inter)retation A single root canal should appear tapering from cro(n to ape,A sudden change in appearance of canal from dar# to light indicates that the canal had -ifurcated or trifurcated) 'ori@ontal root and ma -e confused radiographicall (ith linear patterns of -one tra-eculae) 6ines of -on tra-ecular e,tend -e ond the -order of the root (hile root and often cause thic#ening of PD6) *adiographic differentiation of e,ternal and internal resorptoin) Internal R / have sharp smooth margins and the pulp CdisappearsB into the lesion) E*ternal R / unaltered) 5 Shift method can -e used to differentiate internal and e,ternal resorptionA here the position of internal resorption is unaltered lesions of cancellous -one onl are not seem in radiograph until the cortical -one has -een reached or penetrated) Radiogra)!ic %isinter)retation Presence of periapical radiolucenc on a tooth does not indicate a diseased tooth) In man instances an area of rare faction on the root ape, ma -e the super imposition of an image on the ape,) This phenomenon ma -e seenA (here anatom is normal as in ma,illar sinusA incisive and mental foramenA medullar spaceA traumatic -one c sts etc) A num-er of pathological changes in and near the alveolar process ma -e mista#en for true periapical lesions 1) Gon%odontogenic c sts : 6amina dura is intact in all non%odonto-lastic c sts i) ii) 3) Glo-uloma,illar c st lesion appears inverted pear shaped Midline palatal c st lesion occurs in midline) margins not smooth and pulp appears to pass through the lesion

Apical scar : 'istor of apical surger intact lamina dura

?$ Ieroradiogra)! Derived from Gree# (ord C>erosB (hich means dr )

 ;ses a rigid aluminium F selenium coated photoreceptor plate) Plate is electricall chargedA placed in a (ater proof cassetteA positioned in the mouth and e,posed to ,%ra s at a lo(er level of radiation (30 secs)) Plates ma -e reconditionedA recharged and used repeatedl ) Ad,antages i) ii) iii) SharperA cleaner and finer details of images) *adiation dose reduce Pronounced edge enhancement)

F$ Digital s"(stractions radiogra)! ;sed to detect the progress of caries from an incipient lesionA through the D+K) Assessment of healing or e,pansion of periapical lesion after root canal therap ) Measured the changes in the densit of the lesion) This is an image enhancement methodA resulting in the area under focus -eing clearl displa ed against a neutral gra -lac# -ac# ground i)e) re8uired areas are enlarged against the entire -ac#ground) VITALITY TESTS 1$ T!er%al tests 'eat &old 'eat F cold tests are performed - placing the stimuli on inciso%la-ial (anterior) surface or occluso%-uccal (Posterior) surface) Cold Test Includes air -lastA cold (ater -athA eth l chloride stic#s of iceA car-on dio,ide ice stics# (%9:o&) (ehrmann) +th l chloride and cold (ater -ath are more commonA #ept in contact (ith the tooth) /or 0 seconds or until patient feels pain) Disadvantage (ith car-on dio,ide Snow 5J causes infarction lines in enamel) Aerosol of dichloro difluoromethane (as introduced to su-stitute car-on dio,ide sno(

6eat test &an -e performed (ith hot airA hot (aterA hot -urnisherA hot gutta perchaA hot compound polishing of cro(n (ith a ru--er cup) Most commonl gutta%percha stic# used) Preferred temperature upto 10=o/ according to *o(e et al (1<<=) or 70)0o&)

% *esponses to thermal tests) Sensor fi-res of pulp transmit onl pain (hether pulp has -een cooled or heated) 1) Go response non%vital pulp is indicated) 3) Mild to moderate degree of a(areness of slight pain that su-sides (ithin 1%3 sec after stimulate has -een removed normal) 4) StrongA momentar painful response that su-sides (ithin 1%3 secs after stimulus is removed reversi-le pulpitis) !) Moderate to strong painful response that lingers) /or several seconds or longer after stimulus has -een removed irreversi-le pulpitis /alse positive response can occur %J e,cossive calcificationA immature ape,A recent traumaA premedication) 2$ Electric )"l) tests +PT is designed to stimulate a response of sensor fi-res (ithin the pulp electric e,citation) Disad,antages o& EPT 1) &annot -e used on patients having cardiac pace ma#er) 3) Does not suggest the health or integrit of the pulpA simpl indicates the presence of vital sensor fi-res (ith in the pulp) 4) Does not provide an information a-out vascular suppl of pulpA (hich is the true determinant of pulp vitalit ) Anal tic technolog pulp tester (idel used) /irst lip clip is attachedA electrode is coated (ith viscous conductor (tooth paste) and applied on the middle third of facial surface of the cro(n) &urrent flo( should -e increased slo(l until the patient feels a tingling sensation) Thic#er enamel more dela ed response

 +PT false readings 1) A false positive response means pulp is necroticA patient feels sensation in tooth) +lectrode or conductor contact (ith metal restoration or gingiva) Patient an,iet ) 6i8ue faction necrosis ma conduct current to attachment apparatus) /ailure to isolate and dr the teeth (saliva) 3) /alse negative response means that pulp is vitalA -ut patient does not respondA Patient heavil pre medicated (ith analgesicsA alchohol or tran8uili@ers Inade8uate contact (ill electrode or conductor and enamel) *ecentl traumati@ed tooth +,cessive calcification of canal) *ecentl erupted tooth (ith immature ape,) Partial necrosis 3$ Test Ca,it Performed (hen other diagnostic methods have failed) Test cavit is made - drilling through enamel dentin Dunction of unanaesthetised tooth) Sensitivit or pain felt is an indication of pulp vitalit ) 4$ Anaest!esia test Performed (hen usual tests have failed to ena-le one to identif the tooth) .-Dective is to anaestheti@e a single tooth at a time until the pain disappears and is locali@ed to specific tooth) @$ Laser Do))ler Blow%etr 6D/ (as introduced (first in 1<93 to determine -lood flo( in retina of ra--its of *ivaA *oss and Eende#) as a non%invasive method to measure the -lood flo() Reasons

Reasons

 This techni8ue uses a helium neon laser light -eam that is directed into the tooth) 6ight that contacts a moving o-Dect is Doppler shiftedA and a portion of that light to photodetectorA and a signal is produced As red -lood cells represents the maDorit of moving o-Dects (ithin the toothA measurements of -ac# scattered light serves as an inde, of PE/) Disadvantages is measurements are sensitive to ar,e facts such as movement or pressureA e8uipment is -ul# and costl ) E$ P"lse o*i%etr .,imetr refers to determination of percentage of o, gen saturation of circulating arterial -lood) Matt!es father of o,imetr (1<4! 1<!!) Milli+an coined the term CPulse o,imetr B Pro(e sensor consists of t(o light emitting diodesA one to transmit red light (7!= mm) and other to transmit infra red light (<7= mm) and photo detector on opposite side of vascular -ed) 'ell o, genated -lood appears -right red (:1I) ?$ LiC"id cr stal testing 'o(ell et al (1<9=) emplo ed the color change of cholisteric li8uid cr stals applied to surfaces of the teethA as diagnostic modalities &hanges in temperature or pressure alter the pitch and period of helical structureA so ne( colors are produced) Pulpless teeth e,hi-ited lo(er surface temperature than those (ith vital pulp) F$ 6"g!es Pro(e e ca%era &apa-le of deteching temperature changes as small as =)1o&) ;sed to measure pulp vitalit e,perimentall Dltra so"nd real ti%e i%aging techni8ue that helps in differential diagnosis -et(een c sts and granulomes revealing the nature of content of -on lesion)

 It (idel used in medicineA -ased on the phenomenon of reflection of ultra sound (aves (echoes) at interfaces -et(een tissues that have different acoustic properties) ' poechoic or transonic lo( echo intensit anechoic no reflection of echoes occurs in an area filled (ith fluid) ' perechoic high echo intensit (Eone) & stic lesions %J h po echoicA (ell contoured cavit A surrounded - reinforced -one (allsA filled (ith fluidsA no evidence of internal vasculari@ation on color po(er Doppler e,amination Granuloma : Poorl defined lesionA could -e h per echoic or -oth h po ? h per echoicA e,hi-iting rich vascular suppl on color Doppler e,amination Co%)"teri9ed to%ogra)! Elends concept of thin laser radiograph (ith the computed image) Techi-ena has reported use of &T in endodontics Possi-le to determine -ucco%lingual and mesio%distal (idths of teeth) Presence or a-sence of root canal filling materials and posts) &arious lesionsA e,tension of ma,illar sinusitis and pro,imit to root apices) MAGNETIC RESONANCE IMAGING Magnetic fields and radiographic (aves are used to generate high 8ualit cross sectional images of the -od ) &an distinguish -lood vessels and nerves from surrounding soft tissues) Disadvantages : Got to -e used in patients (ith cardiac face ma#ers metallic restorations F ortho appliancesA ane"r sons) COMPDTERIKED EIPERT SYSTEM *eported - Kohn /irriola &omende, (&+S) used for diagnosis of selected pulpal pathosis (hich is :% % Gormal pulps % *eversi-le pulpitis % Irreversi-le pulpitis due to h per occlusion

% Irreversi-le pulpitis % Gecrotic pulp % Infection due to endodontic failure Diagnostic case foc#s are o-tained and this data entered into the computer) The computer chec#s and gives out the diagnosis) T"ned a)ert"re co%)"ted to%ogra)! :TACT8 Ge( t pe of imaging device that decreases the super imposition of overl ing anatomical structures) TA&T s stem uses digital radio graphic images and the TA&T soft (are correlates the individual images of a su-Dect into a la ering of images that can -e vie(ed into slices) TA&T image is composed of series of : digital radiographs that are assimilated into one reconstructed TA&T image) ;sed in visuali@ation of canals in human molars) +valuating primar simulated recurrent dental caries and simulated osseous defects) Ge( tool to diagnosis e,ternal root resorption at an earlier stages) Disad,antage / Slice o-tained (ere 1)30 mm thic# (hich might -e too thic# and man of the lesions might have -een missed) In&rared t!er%ogra)! Alterations in the temperatures of diseased -odil structures have -een detected (ith sophisticated infrared thermographic e8uipment) It has -een assumed that teeth (ith vital pulps (ould have higher surface temperature than those (ith necrotic pulps)

Diagnosis o& crac+ed toot! s ndro%e$ &rac#ed tooth s ndrome is defined as the incomplete fracture of natural cro(n of a premolar or molar tooth) Gi--s n 1<0! termed it C&uspal fracture odontalgiaB

 *itche

et al 1<09 % reported various cases of incomplete fractures (ith

su-se8uent pulpitis &ameron 1<7! termed Ccrac#ed tooth s dromeB) Also called Cgreen stic# fractureB or Csplit tooth s ndromesB) Incomplete crac#s are either limited to the cro(n or ma &om-ined fractures are called Csplit root s ndromeB) 1) Transillumination test: 6ight from fi-re optic is applied from -uccal surface to illuminate the tooth to detect fractured lines (hen present) 3) Eiting test an orange (ood stic#A or cotton (ood stic# or ru--er (heel or tooth sloth is placed on occlusal (incisal aspect of the tooth and patient is as#ed to -ite) Sharp pain on che(ing of hard or tough food is ver important diagnostic evidence of crac#ed tooth) This t pe of pain is triggered as the pressure is released) 4) Staining: remove the filling from suspected tooth and place 3I Iodine in the cavit preparation) Iodine stains the fracture li#e dar# %et! lane (l"e d e also "sed$ Mi, a d e (ith N.+ and place it is cavit preparation after filling has -een removed) D e (ill seep out and color the fracture line) 'ave a patient che( disclosing ta-let after ta#ing out filling in suspected fracture tooth) 6ine (ill -e stained) GDTTA PERC6A POINT TRACING 'IT6 A RADIOGRAP6Y P"r)ose/ can locali@e the endodontic lesion to the specific tooth) Aids in differential diagnosis -et(een a periodontal and an endodontic lesion) Tec!niC"e/ place a gutta percha point through the sinus F fistula tract and ta#e a radiograph) include root also)

Treat%ent )lanning A treatment plan is a carefull se8uenced series of services designed to eliminate or control etiologic factorsA repair e,isting damageA and create a functionalA maintaina-le environment)

Treat%ent )lan seC"encing ;rgent phase &ontrol phase *e%evaluation phase Definitive phase Maintenance phase) Drgent )!ase A patient presenting (ith s(ellingA painA -leeding or infection should have these pro-lems managed as soon as possi-le and certainl -efore initiation of su-se8uent phases) Control )!ase Is meant to 1) +liminate active diseases such as caries and inflammation) 3) *emove conditions preventing maintenance 4) +liminate potential causes of disease) !) Eegin preventive dentistr activities) Goals of this phase are to remove etiologic factors and sta-ili@e the patients dental health) +,ample : of control phase treatments include 1) +,tractions 3) endodontics 4) Periodontal de-ridement and scaling !) .cclusal adDustment 0) &aries removal 7) *eplacement or repair of defective restorations 9) ;se of caries control measures) * Pre,ention and %anage%ent o& caries C!e%ical 5 use of anti micro-ial agents to alter oval flora and administration of topical fluoride) S"rgical 5 *emoval of diseased tooth structure and replacement (ith restorative material

Re!a,ioral 5 help the patients develop s#illsA #no(ledge and #no(ledge to alter deleterious dietar inta#e and improve oral h giene Mec!anical 5 mechanical alteration of tooth structure at high ris# (e,ample sealants) Dietar 5 alterations of the character of the diet Ot!er - stimulation of salivar medications and use of artificial saliva) *Re5e,al"ation )!ase The holding phase is a time -et(een control and definitive phases that allo(s) /or resolution of inflammation and time for healing) 'ome care ha-its are reinforcedA motivation for further treatment is assessedA and initial treatment and pulpal responses are re%evaluated -efore definitive care is -egun) * De&initi,e P!ase This is the corrective phase (hich includes endodonticA periodonticA orthodontic oral surgical and operative procedures -efore fi,ed or remova-le prosthodontic treatment) All teeth to -e restored (ith large or east restorations should have pulpal F periapical evaluation) If indicated the should have endodontic treatment -efore restoration is completed) +ndodonticall treated teeth (ith no evidence of healingA or has inade8uate fill should -e evaluated for retreatment) Maintenance )!ase *egular recall e,aminations that 1) Ma reveal the need for adDustments to prevent future -rea#do(n 3) Provide an opportunit to reinforce home care) 4) /re8uenc of recall e,amination depends on patients ris# for dental disease) !) 6o( ris# patients %J <%13 month interval 'igh ris# patients %J 4 ! months interval) CONCLDSION flo( through increased che(ingA alteration of

Proper diagnosis and treatment planning pla a critical role in the 8ualit of dental care) +ach patient must -e evaluated individuall in a through and s stematic fashion) After the patients condition is understood and recordedA a treatment plan can-e developed and rendered) +,aminationA diagnosisA and treatment planning are e,tremel challenging and re(arding for -oth the patient and the dentist if done thoroughl and properl (ith the patients -est interest in mind) REBERENCES 1) .perative Dentistr (!th edition) E Sturdvent) 3) +ndodontics (0th edition) Ingle and Ee#land 4) Path(a s of pulp (:th edition) &ohen and Eurns !) +ndodontic Practice Grossman 0) The dental pulp (4rd edition) Samuel selt@er K)E) Eender 7) +ndodontic therap (!th edition) "iene 9) Principle and Practice of endodontics "eltons Tora-ineDad :) &olor Atlas of Dental Medicine +ndodontolog *udolf EeerA EaumennA Lin) <) &olor Atlas of endodontics "illiam T) Kohnson 1=) Pic#ards manual of operative dentistr (:th edition) LiddsA Smith and "atson 11) ;ltra sound real time imaging in differential diagnosis of peri apical lesion +)&otti et al (I+K) 47A 007%074A 3==4) 13) Pulse o,imetr a diagnostic instrument in pulp vitalit testing A)L) MunshiA Amitha M) 'egde (K) &lin) Ped) Dent) 37(3)A 1!1%1!0A 3==3) 14) 6aser Doppler /lo(metr measurements of pulpal -lood flo( and severit of dental inDur * +nshoff et al (I+KA 49A !74%!79A 3==!) 1!) Diagnosis of e,ternal root resorption using TA&T Gance *)S)A T ndoll D (+ndo dent) Troum 3==A (17)A 3!%3:) 10) 5uantitative light induced fluorescence (56/) potential method for dental practitioner *os(itha 'einniel "elt@ein (5uint) Int) 3==4A 4!%4:A 1:1%1::) 17) DiagnosisA therap and prevention of crac#ed tooth s ndrome "erner Geurtsen et al (5uint) Int) 3==4A 4!A !=<%!19))