Diagnosis of Pulpal pathology

Abdullah Karamat

The process of making a diagnosis has five stages:1- Patient tells the clinician why the patient is seeking advice2- The clinician questions the patient about the symptoms and history that led to patient’s visit

3- The clinician performs objective clinical tests.4- The clinician correlates the objective findings with the subjective details and creates a tentative differential diagnosis.5- The clinician formulates a definitive diagnosis

History

• Presenting complaint : Patients should be

questioned sympathetically and asked to describe their complaint in their own words; this should then be documented.

• History of presenting complaint : The history

of presenting complaint is divided into five basic directions of questioning :1- Localization: “Can you point to the offending tooth?”

2- Commencement: “When did the symptoms first occur?”

3- Intensity: “How intense is the pain?”

4- Provocation and Relief of Pain: “What produces or reduces the symptoms?”

5- Duration: “Do the symptoms subside shortly, or do they linger after they are provoked?”

• Dental history :

- Past dental clinic attendance

- Possible contributing factors towards patient’s present condition.

- Proper documentation

• Medical history :

Examination

• Vital signs :- Blood pressure normal for people under 60 years age = 120/80 mmHg and for people above 60 years age = 130/90 mmHg - Pulse rate normal = 60-100/min- Respiratory rate normal = 16-18 breaths/min- Temperature = 98.6 F

• Extra oral examination :Examine for :1- localized swellings2- facial asymmetry3- change in color4- lymph node examination

5- trauma6- sinus tract7- cancer screen ( soft tissue examination , lumps and white spots )8- temporomandibular joint

Intra oral examination :Examine for :1- intra oral swellings2- soft tissue examination3- intra oral sinus 4- hard tissues

To locate the source of an infection, the sinus tract canbe traced by threading the stoma with a gutta-percha point

Palpation :• The buccal/labial and

palatal/lingual mucosa are palpated . Light finger pressure is applied in a rolling motion on the soft tissues using, normally, an index finger . Signs of tenderness usually indicate inflammation of the underlying tissue.

Light finger pressure is applied in a rollingmotion to palpate the soft tissues

PercussionTeeth are percussed in an axial and buccal direction using a forefinger or the end of a mirror handle. Tenderness to gentle percussion indicates inflammation of the periodontal ligament surrounding the tooth; or this may be of pulpal or periodontal in origin .

Tooth percussion performed using a forefinger

Periodontal probing :Probing depths should be assessed by ‘walking’ the periodontal probe around the entire circumference of the tooth . The probing profile for root fractures and iatrogenic perforations is, characteristically, an isolated localised loss of attachment

The periodontal probe must be walked aroundthe tooth to ensure that any isolated narrow periodontaldefects are not missed.

Mobility :Like percussion testing, an increase in tooth mobility is not an indication of pulp vitality. It is merely an indication of a compromised periodontal attachment apparatus.

Mobility testing of a tooth, using the back ends of twomirror handles.

INVESTIGATIONS:

1- Pulp sensitivity tests :Currently available sensitivity tests assess the neural response, and not the vascular supply of the pulp . The assumptionwith these tests is that the neural status reflects the blood supply status of the tooth.

a- Cold test :- ice sticks 0 C- ethyl chloride -50 C- Frozen Carbon dioxide -78.5 C

•

False positve : If cold contacts gingiva or is

transferred to adjacent teeth with vital pulps.

False-negative :Is often obtained when cold is

applied to teeth with calcified canals,

b – Heat tests :- Hot water- Hot burnisher- Hot green stick compound- Heated GP

c- Electrical pulp testing :

The probe tip will be coated with a medium such as toothpaste and placed in contact with the tooth surface. The patient will activate the unit by placing a finger on the metal shaft of the probe .

These testers other electrical testers but are more user friendly. High readings indicate necrosis. Low readings indicate vitality. Testing normal control teeth establishes the approximate boundary between the two conditions. The exact number of the reading is of no significance and does not detect subtle degrees of vitality, nor can any electrical pulp tester indicate inflammation

d – Laser Doppler flowmetry :A diode is used to project an infrared

light beam through the crown and pulp chamber of a tooth. The infrared light beam is scattered as it passes through the pulp tissue. The Doppler principle states that the light beam will be frequency-shifted by moving red blood cells but will remain unshifted as it passes through static tissue

e- Pulse oximeter :

It is designed to measure the oxygen concentration in the blood and the pulse rate.

f- Test cavity preparationHistorically, test cavity preparation has been suggested as a technique to assess the pulp status when all other tests are inconclusive. Local anaesthetic is not administered and a small bur is used with copious irrigation to prepare a small cavity down the centre of the tooth into dentine. If the patient feels sensitivity, this may indicate that the tooth is vital; alternatively, it may indicate that the tooth is unhealthy as Aδ fibres may still be viable in necroticpulp tissue.

g - Bite/cusp loading testsTenderness to bite is indicative of inflammation of the periodontium and a common presenting symptom. The more specific cusp loading bite test using some form of wedging device is indicated for patients with a suspected cusp, tooth or root fracture presenting with poorly localized pain on biting.The patient is instructed to bite firmly on a cotton roll or a commercially available ‘Tooth Slooth’

h- Staining and Transillumination :To determine the presence of a longitudinal fracture of the tooth, the application of a stain to the area is often of great assistance. Applying a bright fiberoptic light probe to the surface of the tooth is also helpful

i- Radiographs : - Radioisuography- Xeroradiography- Digital subtraction radiography- CT- MRI- CBCT

Liquid Crystal Testing :Cholesteric liquid crystals

have been used by investigators to show the difference in tooth temperature between teeth with vital (hotter) pulps and necrotic (cooler) pulps.

Hughes Probeye camera : Is capable of detecting

temperature changes as small as 0.1°C, has also been used to measure pulp vitality experimentally

Selecting the Appropriate Pulp Test : The selection depends on the situation. When

cold (or hot) food or drink initiates a painful response, a cold (or hot) test is conducted in place of other vitality tests. Replication of the same symptoms in a tooth often indicates the offender. Overall, electrical stimulation is similar to cold (refrigerant) in identifying pulp necrosis; heat is the least reliable stimulus.

Differential diagnosis :

• Pulpal conditionsa- Normal pulpA tooth with a normal pulp will be symptom-free. The results of clinical examination will be unremarkable, and the tooth will respond normally to sensitivity testing

b- Reversible pulpitisThere is mild or transient pulpal inflammation. This may result in the tooth causing sharp pain lasting for up to 5–10 seconds, which does not linger, after the applied stimulus has been removed. Common causes of reversible pulpitis include caries and coronal leakage

c- Irreversible pulpitisThe pulp has suffered a more severe insult and is irreversibly inflamed; therefore, the tooth cannot be treated conservatively. Symptoms of irreversible pulpitis may range from a throbbing pain, initiated by hot or cold stimuli and lasting minutes to hours, to spontaneous intermittent bouts of aching pain lasting for hours. Symptoms may be exacerbated when the patient lies down or bends over ( Barodontalgia )

Hyperplastic PulpitisHyperplastic pulpitis (pulp polyp) is

a form of irreversible pulpitis that originates from overgrowth of a chronically infl amed young pulp onto the occlusal surface. It is usually found in carious crowns of young patients . Ample vascularity of the young pulp, adequate exposure for drainage, and tissue proliferation are associated with the formation of hyperplastic pulpitis.Usually asymptomatic

d- Pulp necrosis :This term describes the partial or

complete necrosis of the pulp caused by a loss of, or inadequate blood supply. If the necrotic tissue has not become infected, then the periapical tissues will appear normal radiologically. Until the periodontium is involved, the tooth is usually symptom free.

Periapical conditionsa- Normal periapical tissuesThe tooth is symptom-free and there is no tenderness to palpation or percussion. Radiological examination will reveal a normal periodontal ligament space and no evidence of periapical pathosis.

b- Acute apical periodontitisThe tooth in question will be exquisitely tender to touch, biting or percussion. Radiological examination may reveal a slight widening of the periodontal ligament space. A negative response to sensitivity testing indicates an endodontic cause.

c- Acute periapical abscessPatients suffering from acute periapical abscess will usually present complaining of an intense throbbing pain. The tooth in question will be very tender to touch, percussion and palpation. There may be discernible mobility as the tooth is elevated from its bony socket. The tooth will not respond to sensitivity tests. An intra or extraoral swelling may be present

d- Chronic apical periodontitisPatients may be symptom-free, alternatively, they may report that the tooth feels different or it may be slightly tender to chewing. Clinically, the tooth may be tender to percussion or palpation and does not respond to sensitivity testing. Radiologically, there may be a widening of the periodontal ligament space or more usually, a periapical radiolucency may be present

e- Chronic periapical abscessThe tooth is usually symptom-free, not sensitive to biting pressure but may ‘feel different’ to the patient upon percussion. It is not responsive to pulp sensitivity tests and radiologically, there will be a periapical radiolucency. Chronic periapical abscess may be distinguished from chronic apical periodontitis because the former will usually be associated with a draining sinus tract.

References : 1- Harty

2- Torabinejad3- Ingle 4- Weine 5- Jayshree and Hedge