Review of Diagnostic Procedures, Radiography, Medicaments, and Non-vital bleaching

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Review of Diagnostic Procedures, Radiography, Medicaments, and Non-vital bleaching

Diagnostic Procedures in Endodontic

To avoid misdiagnosis, a step-by-step systemic approach to endodontic diagnosis must be followed. The diagnosis is made from an examination that has both subjective and objective components.

Subjective component: includes evaluation of the symptoms described by the patient.

  • Chief complaint

  • Dental history

  • Medical history (illness, medication, bleeding, or pregnancy)

Objective component: includes evaluation of the symptoms observed by the dentist.

I- Subjective component

Chief Complaint

A description of the dental problem for which the patient seeks care. These include the patient’s description of the location, intensity, and duration of the pain.

Dental History

May provide information concerning injury to the tooth, recent restoration, scaling, or dental trauma.

Medical history

Most medical conditions do not contraindicate endodontic therapy. But, the patient’s medical condition should be thoroughly evaluated in order to properly manage the case.

II-Objective component

Clinical Examination

  • Vital signs: blood pressure, pulse rate, respiration, and temperature.

  • Extraoral examination: includes examination of the face, lips, and neck. The patient must be examined for asymmetries, localized swelling, changes in the color or bruises, scar or trauma.

  • Intraoral examination: includes examination of the oral vestibules and buccal mucosa for localized swelling, sinus tract, color changes, examination of the teeth with gross caries or intensive restoration, teeth restored by full coverage, malocclusion, and broken filling.

  • Periodontal evaluation: pocket measurement, gingival and sulcular bleeding, plaque and calculus.

Pulpal Evaluation:

There are several ways of obtaining information about the condition of the pulp and the supporting structure. These includes:

  • Thermal stimuli

  • Percussion test

  • Palpation test.

  • Mobility test.
  • Electric pulp test

  • Transillumination test

Control Teeth

A healthy tooth located in the opposite quadrant used during each type of pulp testing procedure to the let the patient know what to expect and to allow the dentist to observe the level of response on a healthy tooth.

Thermal Tests

Two types of thermal tests are available:

- cold test

- hot test

Thermal testing can be used for testing teeth with full coverage and to differentiate between vital and necrotic pulps.

Cold Test

  • The cold test may be used in differentiating between reversible and irreversible pulpitis and in identifying teeth with necrotic pulps.

  • Cold testing can be made with a cold drink, an ice stick, ethyl chloride on a cotton swab, or a CO2 dry “ice stick.”

  • When testing with a cold stimulus, one must begin with most posterior tooth and advance toward the anterior teeth. Such a sequence will prevent melting ice water from dripping in a posterior direction and possibly excite a tooth not yet tested into giving a false response.

  • The suspected tooth is isolated (with cotton roll) and dried.

  • The source of the cold is applied to cervical area (Not on metallic restoration) of the control tooth and then to the suspected tooth.

  • If the pain persist after removal of the stimulus, that is taken as evidence for irreversible pulpitis. But if the pain subsides immediately after

  • stimulus removal, hypersensitivity or reversible pulpitis is more likely diagnosis.

  • Necrotic tooth (non-vital) will not respond to cold, therefore it needs RCT

Hot Test

  • Not a very useful test, and not done often.

  • Made with a stick of heated gutta-percha, rubber disc, or hot instrument.

  • For routine heat testing, gutta-percha is warmed, formed into a cone, applied to a warmed instrument, reheated, and applied to the moistened tooth (so that it will not adhere), usually the facial surface of the tooth.

  • Necrotic tooth (non-vital) will not respond, therefore it needs RCT.

Percussion Test

  • To determine whether the inflammation process has extended into the periapical tissue. Positive response to percussion indicates that there is inflammation in the periodontal ligament and endodontic treatment is required.

  • Use a mirror handle and very gently tap the occlusal / incisal surfaces of several teeth in the area in question.

Palpation Test

  • To determine whether the inflammation process has spread from the periodontal ligament to the periosteum overlying the bone.

  • Positive response indicates there is inflammation in periodontal ligament and endodontic treatment is required.

  • Apply firm pressure to the mucosa above the apex of the root.

  • The pressure is usually applied by the tip of the gloved index finger. This examination is most effective when it can be made bilaterally at the same time.

Mobility test

- To observe the degree of mobility of the tooth within the alveolus.

- Using index figers, or preferably by the bulnt handles of two metal instruments, the clinician apply alternating lateral forces in a facial – lingual direction.

Electric Pulp Test

  • It is designed to apply an electrical stimulus to the tooth to determine whether a pulp is vital or non-vital.

  • This test may give false response; therefore, the test results must be supported by other diagnostic findings to arrive at correct diagnosis.

  • To achieve consistent results with an electric pulp tester, follow a standard procedure:

  1. Describe the procedure to the patient and explain that she may feel a tingling or warm sensation.

  2. Isolate the teeth to be tested and dry them thoroughly.

  3. Clean the tip of the electrode with alcohol swap.

  4. Cover the tip of the electrode with toothpaste.

  5. Place the tip of the electrode on the incisal \ occlusal third of the tooth to avoid false stimulation of gingival tissue.

  6. Test the control tooth first.

  7. A record must be made of the result of each tooth tested.

- In some devices it is automatic (as here in the college), other devices, the dial (current level) must be first set at zero, then gradually increased till the patient feels a sensation.

- The doctor must take off gloves to complete current, or ask the patient to hold the electrode to complete current.

Factors that can influence the reliability of the pulp tester:

  • Enamel thickness

  • Probe placement on the tooth

  • Dentin calcification

  • Interfering restorative materials

  • The patient level of anxiety

  • Multi-rooted teeth

  • A recently erupted tooth

  • A young tooth traumatized by impact

  • Liquified necrosis.

  • Moisture on the tooth during testing.

Transillumination Test

This test is useful in identifying teeth with vertical crown fractures

  • A small, intense light source (usually fiber optic) is directed (from the lingual side) through the tooth.

  • Transillumination produces shadows at the fracture site.

Diagnosis of tooth:

  • Normal No subjective or objective symptoms and normal response to stimuli.

  • Reversible pulpitis  There is pain in response to thermal stimuli, however, the pulp is vital, no pain or pulp exposure

  • Irreversible pulpitis  There is lingering pain to thermal stimuli; pulp is not vital and need root canal treatment.

  • Necrotic pulp  There is no response to thermal stimuli or electrical pulp test. The pulp is not vital and need root canal treatment.

Endodontic Radiography

Radiographs are indispensable tools in root canal therapy.

Endodontic Films should show:
  • At least 5mm of bone beyond the apex of the tooth is visible.

  • The tooth is centered on the film.

  • The image is an anatomically correct as possible i.e. no elongation or shortening with good contrast.

In anterior teeth, the clinician may require only one type of radiograph (straight), but in premolars and molars different angulations (straight and mesial) are required so that the overlying canals may be separated, and can be identified.

Radiographs are needed in several steps during root canal treatment:

  1. Initial radiograph: taken before starting the treatment.

  2. Working length radiograph with one or more files in the root canal (s) to estimate and confirm the length of the root canals.

  3. Master apical file radiograph with the final sizes of files in all canals

  4. Master cone radiograph to confirm the position and adaptation of master gutta-percha cone.

  5. Intermediate radiograph to evaluate the quality of the adaptation of master gutta-percha cone with two accessory cones.

  6. Final radiograph to evaluate the final root canal filling.

Pharmacological Agents used in Root Canal Treatment

  • Intracanal medicaments (CMCP, IKI, formecresol, Ca(OH)2 )

  • Irrigating Solution (saline, sodium hypochlorite).

  • Lubricants

  • The choice of the antiseptic is guided by the need for strong antimicrobial agents combined with biocompatibility.

  • Most of these medicaments {Camphorated Paramonochlorophenol (CMCP), Iodine potassium iodide (IKI) and Formecresol} have been discontinued in root canal therapy due to their relative toxicity.

- The one which is more recommended as intracanal medicament is Calcium Hydroxide Ca (OH) 2

  • It is available into two forms: powder or ready mixed (paste)

  • The powder form can be mixed with water, local anesthesia, or saline to have a paste consistency. Barium sulfate can be added to the mix in order to be seen on the radiograph.

  • It delivered to the root canal by endodontic file (in anti-clockwise direction) or lentulo-spirals (clockwise direction) or by messin-gune.

Irrigating Solution

The primary objective of an irrigating solution is to:

  1. Disinfect the root canal

  2. Facilitate the transport of debris during the mechanical instrumentation.

  3. Dissolve the organic debris.

  4. Acts as a lubricant and prevent canal blockage by dentin chips.

Irrgants can either be:

  1. Saline
  2. Sodium Hypochlorite (NaOHCL)


e.g. Rc.prep.

  • They have lubricating properties and facilitate instrument movement within the canal

  • They recommended during the early stage of preparation in case of narrow canals to eliminate soft tissue blockage and facilitate cleaning and shaping of the root canal.

Non-Vital bleaching
Bleaching can be used for whitening discolored teeth.

It can be done for all teeth (vital) bleaching, or for specified discolored teeth( nonvital) bleaching.

Nonvital bleaching is done after root canal treatment.

Discoloration could be:

  1. Intrinsic discoloration

Tetracycline or minocycline or fluoride

  1. Extrinsic discoloration

Dark colored food, beverages, tobacco, incomplete old root canal therapy, leaking composite or amalgam restorations

  1. The root canal therapy is checked and the shade of the tooth is recorded.

  2. A barrier is placed between gutta-percha and the bleach such as glass ionomer, IRM, or cavit.

  3. A mixture of sodium perborate and superoxol is mixed in 1:1 ratio and placed in canal.

  4. A heating instrument is placed on the material to activate for 1-3 minutes.

  5. A restoration is placed.

  6. The procedure is repeated at next visit if needed till the correct color is reached.

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