Pulpal & periradicular diseases & their diagnosis

DISEASES OF
PULPAL &
PERIRADICULAR
TISSUE…
1
ADITI SINGH
P.G DEPT. OF PEDODONTICS
SDCH

THE HERO----PULP
THE PROBLEM---DISEASES OF PULP
SIDEKICKS----PERIRADICULAR TISSUE
THE PROBLEM PART 2 ---DISEASES OF PERIRADICULAR
TISSUE
THE STORY---DIAGNOSIS OF PULP DISEASES
INTERVAL --- CONCLUSION
CONTENTS
2

The dental pulp is a delicate soft connective tissue interspersed
with tiny blood vesels,lymphatics ,myelinated & unmyelinated
nerves & undifferentiated connective tissue cells that supports the
dentin.
PULP
Chandra SB,Gopikrishna V;Grossman’s Endodontic Practice 12 Ed;
2010;Wolters Kluver
4

CLASSIFICATIONS….
Abbott, PV,Yu C;A clinical classification of the status of the pulp and the
root canal system;Australian Dental Journal Supplement 2007;52:(1 Suppl):S17-S31
WHO AAE glossary
Normal pulp not mentioned Normal pulp not mentioned
Pulpitis :
Initial (hyperaemia
Acute suppurative
Chronic (ulcerative / hyperplastic)
Other unspecified pulpitis
Pulpitis :
Reversible
Irreversible
Pulp
necrosis
Pulp
Necrosis
Pulp degeneration :
Denticles
Calcification
Stones
Abnormal hard tissue formation in pulp
Secondary or irregular dentin
6

Weine Ingle Cohen & Burns
Normal pulp not
mentioned
Healthy pulp Normal not mentioned
Pulpitis
Hyperalgesia
Hypersensitive dentin
Hyperemia
Painful pulpitis
(Acute, Chronic)
Nonpainful pulpitis
(Chronic ulcerative ,
Chronic pulpitis,
Chronic hyperplastic
Pulpitis:
Hyper-reactive
pulpalgia
Hypersensitivity
Hyperaemia
Acute pulpalgia
Chronic pulpalgia
Hyperplastic pulposis
Pulpitis:
Reversible
Irreversible
Asymptomatic
Hyperplastic
Internal resorption
Canal calcification
Symptomatic
Pulp Necrosis Pulp necrosis Necrosis (Partial or
complete)
Pulp Degeneration Pulp degeneration
Internal resorption Internal resorption
root canal system;Australian Dental Journal Supplement 2007;52:(1 Suppl):S17-S31
7

REVERSIBLE
ASYMPTOMATIC
SYMPTOMATIC
IRREVERSIBLE
ACUTE/
SYMPTOMATIC
CHRONIC
ASYMPTOMATIC
HYPERPLASTIC
INTERNAL
RESORPTION
PULP
DEGENERATION
CALCIFIC
OTHERS
PULP NECROSIS
THE CLASSIFICATION…
2010;Wolters Kluver
Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.
8

Its not a disease but a
symptom
 mild to moderate
inflammatory
condition of pulp caused by
noxious stimuli
 pulp is capable of returning
to un-inflammed state
following removal of stimuli
REVERSIBLE PULPITIS
Chandra SB,Gopikrishna V;Grossman’s Endodontic Practice 12 Ed; 2010;Wolters Kluve
9

 Causes
 agent capable of
injuring pulp like:
• trauma
• disturbed occlusal relationship
• thermal shock
•Carious lesion
10

 Clinical Features
 sharp pain lasting for
a moment
 often brought on by cold
than hot food or beverages
and by cold air
11

 does not continue
when the cause has been
removed
 tooth responds to electric
pulp testing at lower current
12

Treatment
 Removal of noxious stimulus
Prevention
Early filling of carious lesion
Periodic care
13

earliest form
 also known as pulp hyperemia
 excessive accumulation of
blood within pulp tissue
 leads to vascular congestion
FOCAL REVERSIBLE PULPITIS
14

 sensitive to thermal
changes
 particularly to cold
 application of ice or cold
fluids to tooth result in pain
15

 disappears upon removal
of thermal irritant or
restoration of normal
temperature
 responds to electrical test
stimulant at lower level
of current
16

 indicates lower pain
threshold than that of
adjacent normal
teeth
17

 teeth show:
• deep carious lesion
• large metallic restoration
• restoration with defective
margins
MANAGEMENT : Removal of noxious stimulus before the
pulp is severely damaged.
18

 persistent inflammatory
condition of pulp
 may be symptomatic or
asymptomatic
 caused by noxious stimulus
IRREVERSIBLE PULPITIS
19

 Causes
 bacterial involvement of
pulp through caries
 chemical
 thermal
 mechanical injury
20Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008.

Early Stage
 paroxysm of pain
caused by:
• sudden temperature
changes like cold,
sweet, acid foodstuffs.
21

Early Stage
 pain often continues
when cause has been
removed
 may come and go
spontaneously
22

Early Stage
 pain
• sharp
• piercing
• shooting
• generally severe
23

Early Stage
 pain
• bending over exacerbates pain which
• lying down is due to change in
• change of position intrapulpal pressure
24

Late Stage
 pain
• more severe as if tooth is under
• throbbing constant pressure
25

Late Stage
 pain
• patient is often awake
at night due to pain
• increased by heat and
sometimes relieved by cold,
although continued application
of cold may intensify pain
MANAGEMENT : Endodontic therapy
26

Reversible Pulpitis Irreversible Pulpitis
 pain is generally traceable
to a stimulus
 cold water
 air
 more severe
 lasts longer
 pain may come without
any apparent stimulus
REVERSIBLE Vs IRREVERSIBLE
PULPITIS
27

 extensive acute inflammation
of pulp
 frequent sequel of focal
reversible pulpitis
ACUTE PULPITIS
28

 Causes
 tooth with large carious
lesion
 defective restoration
where there has been
recurrent caries
 pulp exposure due to
faulty cavity preparation
29

 severe pain is elicited by
thermal changes
 pain persists even after
thermal stimulus
disappears or has been
removed
30

 may be continuous
 intensity may be increased
when patient lies down
 application of heat may
may cause acute
exacerbation of pain
31

 tooth reacts to electric
pulp vitality tester at a
lower level of current
than adjacent normal
teeth
32

 pressure increases
because of lack of
escape of inflammatory
exudate
 rapid spread of
inflammation
through pulp with pain
+ necrosis
Management : endodontic
therapy
33

 may develop with or
without episodes of
acute pulpitis
 many pulps under large
carious cavities die painlessly
 1st indication is then
development of periapical
periodontitis, either with pain
or seen by chance in radiograph
CHRONIC PULPITIS
Cohen S,Burns RC; Pathways of Pulp; 6Ed,2008. 34

 dull aching type
 more often intermittent
than continuous
MANAGEMENT : endodontic therapy
35

 also called as pulp polyp
or pulpitis aperta
 essentially an excessive
exuberant proliferation
of chronically inflamed
dental pulp tissue
CHRONIC HYPERPLASTIC PULPITIS
36

 pulpal inflammation due
to an extensive carious
exposure of a young pulp
 development of granulation
tissue
 covered at times by epithelium
 resulting from long standing
low grade infection
37

 Causes
 slow progressive
exposure of pulp
 bacterial infection
38

 most commonly involved
are deciduous molars +
1st permanent molar
• excellent blood supply
• large root opening
39

 asymptomatic
 seen only in teeth of children
+ young adults
40

 polypoid tissue appears
• fleshy
• reddish pulpal mass
filling most of pulp
chamber or cavity or
even extend beyond
confines of tooth
41

• sometimes, if mass is
large enough interferes
with closure of mouth
42

• may cause discomfort
during mastication
due to pressure of food
bolus
43

• tissue easily bleeds
because of rich network
of blood vessels
• tooth may or may not
respond at all to thermal
test

PULP POLYP Vs GINGIVAL
POLYP
PULP POLYP
1.Soft edematous more reddish in
appearance
2.Friable
3. On passing a probe around the
polyp we can trace its origin within
the tooth
4.Endodontic therapy or
extraction in case of hopeless
prognosis
GINGIVAL POLYP
1.Comparitively firm with color
similar to that of adjacent gingiva (
unless secondarily traumatized or
inflamed)
2.Non friable
3. On passing a probe around the
polyp we can trace its origin
around or adjacent to the tooth
4.Remove the etiology for eg.
calculus around the tooth
45

elimination of polypoid tissue followed by
extirpation of pulp
 hyperplastic tissue bleeding
can be controlled by pressure
 extraction of tooth can also
be done
MANAGEMENT
46

 death of pulp
 may be partial or total
depending on whether part
or the entire pulp is
involved
PULP NECROSIS
47

 Causes
 sequelae of inflammation
 can also occur following
trauma
• pulp is destroyed before
an inflammatory reaction
48

 Types
 (1) Coagulation Necrosis
 (2) Liquefaction Necrosis
49

 Types
• soluble portion of
tissue is precipitated or converted into a solid
material
50

 Types
• tissue is converted into
tissue mass consisting
chiefly of coagulated
 proteins
 fats
 water
51

 Types
 (2) Liquefaction Necrosis
• results when proteolytic
enzymes convert the
tissue into softened mass
liquid or amorphous debris
52

 no painful symptoms
 discoloration of tooth
• 1st indication that the pulp
is dead
53

 history of pain lasting from
a few minutes to a few
hours followed by
complete + sudden
cessation of pain
MANAGEMENT : Endodontic therapy
54

1.A mixture of the signs and symptoms of both pulpitis
and necrosis with infection.
2.mild with intermittent painful episodes over many
weeks or months.
3.Pulp sensitivity test results are mixed and frequently
inconclusive or inconsistent with the patient’s
description of symptoms.
4.Teeth with necrobiosis may also have apical
periodontitis with radiographic evidence of a widened
periodontal ligament space, which may be unexpected
because the patient has reported sensitivity to hot
and/or cold stimuli.
NECROBIOSIS
root canal system;Australian Dental Journal Supplement 2007;52:(1 Suppl):S17-
S31
55

Incomplete fracture of a vital posterior tooth that
involves the dentine and occasionally extends into
the pulp.
CRACKED TOOTH SYNDROME
(Cameron 1964)
Lynch CD,McConnell RJ; The Cracked Tooth Syndrome; J Can Dent Assoc 2002;
68(8):470-5 56

Etiology..
68(8):470-5 57

Treatment…
68(8):470-5
Large central crack
No pulp
involvement
Immediate
temporary
Stabilization
Permanent
stabilization
Bonded restoration
or cast metal
restoration
Pulp involvement
Immediate
stabilization + pulp
extirpation
Monitor symptoms
& complete RCT
Hopeless
prognosis
extract
Small peripheral
crack
Remove
compromised
portion
Restore with
composite or
appropriate cast
metal restoration
58

Barodontalgia is a symptom rather than a pathological condition
Its defined as an oral (dental or nondental) pain caused by a
change in barometric pressure in an otherwise
asymptomatic organ.(Zadik Y )
CLASSIFICATION : (FDI)
BARODONTALGIA
59

• Cementing of fixed prosthesis with resin cements for
• patients
• Endodontically treated teeth that have been open for
endodontic treatment and temporarily sealed have been report
to be explode on deep sea diving known as Odontocrexis,
• full porcelain crowns have been reported to shatter at a dive of
65 ft, hence meticulous oral health advice should be given to
the divers,
• all carious lesions should be restored, all ill fitting crowns
should be replaced with a good cementing medium,
• active periodontal lesion treatment and completion of
endodontic treatment should be done.
• Also removable dentures are not recommended rather a FPD
or an implant is indicated.
MANAGEMENT
Gaur TK, Shrivastava: Barodontalgia: A Clinical Entity J Oral Health Comm Dent
2012;6(1)18-20
60

Barotrauma in flight Vs in diving
In flight the theoretically possible
pressure changes range from 1 atm
(at ground level) to 0 atm (at outer
space)
Possible mechanism of barotrauma
1.Direct ischaemia resulting from
inflammation itself
2. Indirect ischaemia resulting from
intra-pulpal increased pressure as
a result of vasodilatation and fluid
diffusion to the tissue
3. The result of intra-pulpal gas
expansion.The gas is a by-product
of acids, bases, and enzymes in the
inflamed tissue
4. The result of gas leakage through
the vessels because of reduced gas
solubility
In diving the changes are more
significant, since each
descent of 10 meters (32.8 feet)
elevates the pressure
by 1 atm.
The most common way for air from
the pressurized tanks to enter a tooth
is by being forced in through carious
lesions or defective margins
As atmospheric pressure decreases
during ascent, trapped gases may
expand and enter dentin tubules,
thereby stimulating nociceptors in the
pulp or causing the movement of pulp
chamber contents through the apex
of the tooth, also causing pain
61

The periradicular tissue comprises of
surroundin Alveolar bone,
periodontal ligament & cementum.
PERIRADICULAR TISSUE
63

CLASSIFICATION..• Acute alveolar abscess
• Acute apical periodontitis
Acute periradicular disease
• Chronic alveolar abscess
• granuloma
• cyst
Chronic periradicular disease
Condensing osteitis
External root resorption
Non endodontic origin
2010;Wolters Kluver
64

K 04.4 : Acute apical periodontitis
K 04.5 : Chronic apical periodontitis (apical granuloma)
K 04.6 : Periapical abscess with sinus
K 04.60: periapical abscess with sinus to maxillary antrum
K 04.61 : periapical abscess with sinus to nasal cavity
K 04.62 : periapical abscess with sinus to oral cavity
K 04.63 : periapical abscess with sinus to skin
K 04.7 : periapical abscess without sinus
K 04.8 : radicular cyst
K 04.80 : Apical and lateral cyst
K 04.81 : Residual cyst
K 04.82 : Inflammatory paradental cyst
WHO CLASSIFICATION
2010;Wolters Kluver
65

PERIAPICAL PATHOLOGY
Symptomatic apical periodontitis (acute apical periodontitis):
a painful response to biting and percussion. It may or may not be
associated with an apical radiolucent area.
Asymptomatic apical periodontitis (chronic apical
periodontitis):It appears as an apical radiolucent area, and does
not produce clinical symptoms
66

ACUTE Vs CHRONIC
gradual onset, little or
no discomfort, and the
intermittent discharge of
pus through an
associated sinus tract.
Acute apical
periodontitis
rapid onset,
spontaneous pain,
tenderness of the tooth
to pressure, pus
formation, and eventual
swelling of associated
tissues
Chronic apical
(periapical) periodontitis
67

An acute apical abscess may result when large numbers of
bacteria get past the apex and elicit a severe inflammatory
response.
.This response is acute, the predominant cell being the
polymorphonuclear leukocyte. With the release of PMN lysosomal
enzymes into the tissue space and the concomitant tissue
degradation, an abscess forms
An abscess is defined as a localized collection of pus which,
microscopically, is composed of dead cells, debris, PMNs, and
macrophages.
ACUTE APICAL ABSCESS
68

CLINICAL MANIFESTATION
varying degrees of swelling occur, with pain.
The patient complains of a feeling that the tooth is elevated out
the socket.
Elevated temperature and malaise may follow. The body respo
to this insult by trying to isolate the abscess and/or establish
drainage either intraorally or extraorally. If drainage is not effect
the abscess may spread into fascial planes or spaces of the he
and neck.
PHONIX ABSCESS
If a periapical radiolucency is present and an acute inflammato
response is superimposed on this preexisting chronic lesion it i
termed a phoenix abscess.
ACUTE APICAL ABSCESS

• Acute osteomyelitis can arise directly from an endodontic
infection.
• Live bacteria are past the apex and now are multiplying in the
marrow spaces and soft tissue of the bone.
• Osteomyelitis may be a serious progression of periapical
infection that results in diffuse spread through the medullary
spaces, ultimately leading to necrosis of bone.
• Acute osteomyelitis may be localized or spread throughout
large areas of bone
ACUTE OSTEOMYELITIS
70

• The patient usually has severe pain, an elevated temperature,
and palpable lymph nodes.
• Although the teeth are loose and sore in the early stages, there
may be no swelling, and radiographic changes are difficult to
detect
• There may or may not be pus formation
• If untreated, the acute form may progress to chronic disease.
• Clinically, chronic suppurative osteomyelitis is the same as
acute except the symptoms are milder and radiographically
diffuse bone resorption is evident.
ACUTE OSTEOMYELITIS
71

TREATMENT
Hyperbaric oxygen
Endodontic therapy or extraction of the carious tooth
More surgical treatment may be required
Aggressive antibiotic therapy to nail the causative bacteria
ACUTE OSTEOMYELITIS
72

• An apical lesion that has established drainage through a sinus
tract is termed suppurative inflammation
• The patient may complain of a "gum boil" or a badtaste in the
mouth.
• Pus may be expressed through the opening by gentle
pressure.
• A radiograph should be exposed with a gutta-percha probe
inserted into the tract to determine the cause of the lesion.
SUPPURATIVE APICAL
PERIODONTITIS
73

• A foreign body response may occur to many types of
substances.
• The reaction can be acute and/or chronic
• These lesions may or may not be symptomatic.
• The cause is now beyond the apex, so surgery may be
necessary to remove the foreign material and effect healing
FOREIGN BODY REACTION
74

• The inflammatory response depends on the quality, duration,
and virulence of the irritant.
• A very low-grade, subclinical response may lead to an increase
in the bone density rather than resorption and radiolucency.
• This lesion may be clinically asymptomatic and
radiographically can demonstrate increased trabeculation and
opacity
• If it is associated with a necrotic or diseased pulp endodontic
therapy may lead to healing
Osteosclerosis or condensing osteitis
75

• This is a chronic inflammatory lesion that has epithelium lining
the lumen, but the lumen has a direct communication with the
root canal system.
• It is not a true cyst, because a true cyst is a three-dimensional,
epithelium-lined cavity with no communication between the
lumen and the canal system
• The distinction between a bay and a true cyst is important
from the standpoint of healing
• While bay cyst can be treated with endodontic therapy true
cyst requires surgical excision (Vaulderhaug , Bhsskar SN
1971;Mortensen etal 1972)
BAY CYST
76

Antibioma is a sterile, chronic abscess formed because of
incomplete treatment of an infection by using antibiotics without
incision and drainage.
It may present with pain, swelling, and tenderness or with mass
effect in the form of neuralgic pain.
ANTIBIOMA
77

CASE HISTORY
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
MEDICAL HISTORY
DENTAL HISTORY
DRUG HISTORY
79

PAIN
MODE OF ONSET : Spontaneous or provoked
FREQUENCY & DURATION : continuous or intermittent
QUALITY OF PAIN :
Dull aching : pain of bony origin
Throbbing or pulsing : Pain of vascular origin
Sharp stabbing recurrent : pathology of nerve
root complex
POSTURAL CHANGES : Pain increases on bending or lying
down indicates pulpal pain
80

TYPE OF PAIN
Momentary pain
Persistent pain
Spontaneous pain
Provoked pain
81

EXTRAORAL EXAMINATION
Facial symmetry
Lymph nodes
TMJ
82

INTRAORAL EXAMINATION
SOFT TISSUSE EXAMINATION
Swelling
Discoloration
Sinus formation
Gingival inflammation
83

VISUAL EXAMINATION
Mobility in primary tooth may be physiological or pathological
WYMAN’S INDEX : 0:horizontal <0.2mm
1 : Horizontal 0.2-1mm
2 : Horizontal 1-2mm
3 : Horizontal >2mm &
Vertical
84

PERCUSSION : can be checked by applying finger pressure on
the tooth or tapping with tip end of handle of the mirror ; if pain
then periodontal ligament is inflamed.
Lateral percussion is done to check for lateral periodontitis or
periodontitis of gingival origin
Apical / vertical percussion is done to check for apical
periodontitis
PALPATION : simple test done with finger tips using light pressure
to examine tissue consistency & pain response
EXPOSURE SITE : Light red blood that can be arrested easily is
associated with inflamed coronal pulp of primary teeth. Deep red
blood indicates that inflammation has extended into the root
canals of primary teeth
Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC
85

PULP TESTING
Thermal Test : Heat Test / Cold Test
No Response
Mild – Moderate response that subsides in 1-2 sec
Strong Momentary pain that subsides in 1-2 secs
Moderate to strong pain for several secs. or longer
Cold tests are most likely to give a positive response in the
cervical area compared to the occlusal surface
86

ELECTRIC PULP TESTING
False positive response :
improper isolation,
liquefactive necrosis of
pulp,apprehensive patient,
electrode contacts with metal
restoration or gingiva
False negative response :
recent trauma to
tooth,calcification of root
canal,immature apex
formation,partial necrosis,
incomplete circuit
formation,Heavy
premedications
• Isolate the tooth to be tested
• Apply electrolyte on the
electrode & place it against
the dried enamel surface
• Retract the patient cheek
with free hand to complete
the circuit
• Apply mild current &
increase slowly
Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker
Inc 87

Jacobson reported that the optimal placement of the probe tip in
vitro was the occlusal two-thirds on the labial or buccal surfaces of
teeth.
Other investigators have reported that the incisal edge was the
optimal placement site to achieve the lowest possible threshold
for an EPT response. The threshold increased as the probe tip
was moved toward the gingival margin.
Jacobson JJ. Probe placement during electric pulp-testing procedures.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1984;58(2):242–7. 88

• Thermal pulp testing depends on the outward and inward
movement of the dentinal fluid, whereas electric pulp testing
depends on ionic movement.
• Because of their distribution, larger diameter than that of C fibres,
their conduction speed and their myelin sheath, A-delta fibres are
those stimulated in electric pulp testing.
• C fibres do not respond to electric pulp testing. Because of their
high threshold, a stronger electric current is needed to stimulate
them.
• Based on the hydrodynamic effect, outward movement of dentinal
fluid caused by the application of cold (contraction of fluid)
produces a stronger response in A-delta fibres than inward
movement of the fluid caused by the application of heat.
• Repeated application of cold will reduce the displacement rate of
the fluids inside the dentinal tubules, causing a less painful
response from the pulp for a short time, which is why the cold test
is sometimes refractory.
Some pointers….
Elmeguid AA Yu DC: Dental Pulp Neurophysiology: Part 1. Clinical and
Diagnostic Implications;JCDA;2009;75(1):55-59 89

• The A-delta fibres are more affected by the reduction of pulpal
blood flow than the C fibres because the A-delta fibres cannot
function in case of anoxia.
• An uncontrolled heat test can injure the pulp and release
mediators that affect the C fibres
• A positive percussion test indicates that the inflammation has
moved from the pulp to the periodontium, which is rich in
proprioceptors, causing this type of localized response
Elmeguid AA Yu DC: Dental Pulp Neurophysiology: Part 1. Clinical and
Diagnostic Implications;JCDA;2009;75(1):55-59 90

Percussion Testing is most reliable in primary teeth. (C Delta
fibres)
Thermal sensitivity Testing & Electrical Pulp Testing are NOT very
reliable in primary teeth( A Delta fibres ) because of failure of
complete development of Rashkow’s nerve plexus
91

RADIOGRAPHIC
INTERPRETATION
Pathologic bone
resorption.
The bone destruction is seen in
the furcation area of the tooth.
The finding of bone resorption
is indicative of widespread
pulpal necrosis and nonvitality
of the associated tooth.
Ingle JE,Bakland LE, Baumgartner JC
;Endodontics 6 ;2008;6Ed; BC Decker Inc
92

Pathologic root
resorption.
Commonly associated with
pathologic bone resorption .
Internal/External
resorption.
It will probably be seen in the
root canals and again is
evidence of advanced
degenerative changes
throughout the pulp. Pulp
therapy will generally not be
successful as the resorptive
process is not readily retarded.
Ingle JE,Bakland LE, Baumgartner JC
;Endodontics 6 ;2008;6Ed; BC Decker Inc 93

Calcific changes. Calcified bodies (known as calcific masses or
globules) present in the pulp indicate advanced pulpal
degeneration with inflammation spread throughout the coronal
portion of the pulp.
Widened periodontal membrane/ligament. A widened PDL is
usually indicative of pulpal pathology.
94

HISTOLOGY Vs RADIOGRAPHY
HISTOLOGIC APPEARANCE RADIOGRAPHIC FEATURES
Incipient apical periodontitis Bone structural changes
Initial inflammation with acute
features
Bone structural changes
Chronic inflammation Bone demineralisation; lesion
area defined
Granuloma or cyst formation Radioluscent area; peripheral
bony rim
Lesion with features of
exacerbation
Bone structural changes
peropheral to lesion
Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker I
95

PERIAPICAL INDEX SCORING
rstavik D, Kerekes K, Eriksen HM. The periapical index: a scoring system for radiographic96

Normal pulp Reversible
pulpitis
Irreversible
pulpitis
Asymptoma
tic
Irreversible
pulpitis
symptomati
c
Pulp
necrosis
signs none
Patient
history
No h/o
spontaneous
pain
No h/o
spontaneous
pain
none Spontanoeus
pain
No pain to
severe pain
Cold test Quick mild
response to
cold which
doesn’t linger
Quick &
sometimes
sharp
response
discomfort
does not
linger
Quick &
sometimes
sharp
response &
discomfort
does not
linger
Exagerrated
response to
cold with
linering pain
No response
Percussion
sensitivity
negative Negative Negative May be
positive
No response
to
exaggerated
response
Radiographic
findings
normal normal Caries
present;
normal pdl or
thickened pdl
Normal pdl or
thickened pdl
Normal
periapex to
large
periapical
radioluscenc
yZero DT, Zandona AF,Macapagal M,Spolnik KJ; Dental caries & pulpal disease ; Dent Clin N Am ;2011; 55;29-46 97

Normal
periapex
Symptomatic
AP
Asymptomati
c AP
Acute apical
abscess
Chronic
apical
abscess
Patient history none Pain when
biting
none Extreme pain
on biting
Usually none
vitality wnl Usually no
response to
vitality
No response
to vitality
No response No response
percussion none positive None to slight positive None to slight
palpation none May or may
not be
positive
WNL positive None to slight
with sinus
tract present
Radiographic
findings
normal Widenend
PDL space or
periapical
radiolusceucy
Periapical
radioluscency
Widened PDL
space to
periapical
radioluscecy
Periapical
radioluscency
Zero DT, Zandona AF,Macapagal M,Spolnik KJ; Dental caries & pulpal disease ; Dent Clin N Am ;2011; 55;29-46
98

Anesthetic testing
(Grossman 1978) Source of
pain may be identified by
giving intraligamentary
anesthetic when all other
tests fail to isolate the tooth in
question
Test Cavity : (Seltzer &
Bender 1975) Every tooth is
drilled upto the
Dentinoenamel junction using
slow speed hand piece
without water. If sensitivity
present then pulp is vital.
Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC Decker Inc
99

Photoplethysmography
• Passing of light through the tooth & measuring existing
wavelength using galvanometer.Vital pulp will show vascular
dilatation on warming it which will be recorded as current on
the galvanometer.
• This is an optical measurement technique that can be used to
detect blood volume changes in the microvascular bed of
tissue.
• The basic form of PPG technology requires only a few
opto-electronic components: a light source to illuminate the
tissue (e.g., skin or tooth) and a photodetector to measure the
small variations in light intensity associated with changes in
perfusion in the catchment (study) volume.
101

• It is a method independent of a pulsatile circulation. The
presence of arterioles rather than arteries in the pulp and its
rigid encapsulation by surrounding dentine and enamel make it
difficult to detect a pulse in the pulp space.
• This method measures oxygenation changes in the capillary
bed rather than in the supply vessels and hence does not
depend on a pulsatile blood flow.
• Oximetry by spectrophotometer determines the level of oxygen
saturation in the pulpal blood supply with a dual-wavelength
light source (760 and 850 nm).
Dual wavelength spectrometry
Tyagi SP, Sinha DJ, Verma R, Singh UP. New
vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90
102

• Teeth with vital pulps fluoresced normally but the teeth with
necrotic or absent pulps do not fluoresce when exposed to
ultraviolet light.
• There are differences in characteristics of healthy dentin and
decayed dentin fluorescence spectra at excitations of 405 nm
and 440 nm UV light
• Fluorescence from the pulp are substantially lower than the
healthy and decayed dentin fluorescence.
FIBREOPTIC FLUORESCENT
SPECTROMETRY
103

• Xeroradiography is an electrostatic process which uses an amorphous
selenium photoconductor material, vacuum deposited on an aluminum
substrate, to form a plate.
• The key functional steps in the process involve the sensitization of the
photoconductor plate in the charging station by depositing a uniform
positive charge on its surface with a corona-emitting device called
scorotron
• The generated latent image is developed through an electrophoretic
development process using liquid toner.
• Soft tissues on xeroradiographic films have well defined outlines that may
permit confident evaluation of the soft tissue height and contour.
• Xeroradiographs provide greater overall soft tissue detail making possible
evaluation of its density, texture, and contents.
• It reveals soft tissues calcifications which are not easily discerned in
conventional radiographs.This property may be employed in endodontics
to visualized early pulpal calcifications.
• detailed visualization of lamina dura, bony trabeculae, fine metal
nstruments like files, broaches etc, root apices, periodontal ligament
spaces
Xeroradiography
Udoye C,Jafarzadeh H : ,Xeroradiography: Stagnated after a Promising Beginning
Historical Review;Eur J Dent 2010;4:95-99)
104

TOOTH TEMPERATURE
Hugeyes Probeye Camera : it can record temperature changes as
small as 0.1oC.it requires thermal video system & silicon close up
lens
Here a color image is produced which indicates a
relative difference in temperature in both superficial and
deep areas.
Computer-controlled infrared thermographic imaging is another
noninvasive method of recording the surface temperature of the
body.
The use of Huges Probeye 4300 Thermal Video System (Hughes
Aircraft Co., Carlsbad, CA) was reported in 1989 by Pogrel et al.[55]
and was found to be sensitive enough to measure temperature
differences as low as 0.1°C.
Newer, less cumbersome, and easier to use models is now available.
Thermography : recording the infrared radiations emitted from the
tooth
105

Pulse Oximetry uses red and infrared
wavelengths in order to transilluminate a
tissue and detects absorbance peaks due
to pulsatile circulation and uses this
information to calculate the pulse rate and
oxygen saturation.
Beer- Lambert’s law: the absorption of
light by a solute is related to its
concentration at a given wavelength.
Pulse Oximetry also uses the
characteristics of hemoglobin .i.e in the
red and infrared range ‘oxy’ hemoglobin
absorbs more light in the red range than
‘deoxy’ hemoglobin and vice versa in the
infrared range.
Oxygen saturation of Pulp.Avg value :
(Pulp) 94% PR : 72/min
PULSE OXIMETER
Tyagi SP, Sinha DJ, Verma R, Singh UP. New vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90.
106

LASER DOPPLER FLOWMETRY
• Doppler frequency shift
• The fraction of light that is
scattered back from the
illuminated area is detected
& processed to give a signal
which is a measure of the
blood flow in the dental pulp
• The total backscattered light
is processed to produce an
output signal which is
commonly recorded as the
concentration and velocity
(flux) of cells using an
arbitrary term “perfusion
units” (PU), (2.5 volts of
blood flow = 250 PU).
107

Transillumination (using Fibreoptic
light)
Incomplete crack in the tooth (greenstick fractures)
Pulp vitality in anterior teeth post trauma.
UV Light :
1.Some objects possess the unusual feature of being able
to emit light of a higher wavelength when illuminated
with UV light. That principle is called fluorescence.
2.Foreman reported that teeth with necrotic pulps and
teeth with endodontic treatment did not fluoresce when
exposed to UV light while teeth with vital pulps
fluoresced normally
Ingle JE,Bakland LE, Baumgartner JC ;Endodontics 6 ;2008;6Ed; BC
Decker Inc
108

• The device uses a transducer (a crystal containing probe), a
coupling agent and software with customized electronic and digital
signal processing algorithms.
• US waves are generated when an alternating current (3-10 MHz)
is applied to the crystal as a consequence of the piezoelectric
effect.
• When the operator moves the probe in the examination area a
change is created on the sector plane, thus producing a real-time
three-dimensional image of that particular space.
• US has the ability to penetrate hard tissues and in principle can
successfully detect discontinuities and pathosis even under
existing radio-opaque restorations.
• Because the different biological tissues in the body possess
different mechanical and acoustic properties, the US waves at the
interface between two tissues with different acoustic impedance
undergo the phenomena of reflection and refraction.
• The echo is the part of the US wave that is reflected back from the
tissue interface toward the transducer.
USG
109

• When applied to US examination, Color Power Doppler
flowmetry allows the presence and direction of the blood flow
within the tissue of interest to be observed.
• The intensity of the Doppler signal is represented by changes
in real time on a graph (Doppler) and is also shown in the form
of color spots on the gray scale image (color).
• Positive Doppler shifts are caused by the blood moving toward
the transducer and are represented in red, whereas negative
Doppler shifts are caused by blood moving in the opposite
direction and are represented in blue.
ULTRASOUND DOPPLER
110

MRI
Best resolution of tissue of low inherent contrast
No ionizing radiations involved
Direct multiplanar image is possible without reorienting the
patient
Disadvantages:
1. Potential hazard due to presence of large ferromagnetic
metals in the vicinity
2. Long imaging time
The nature of periapical lesions could be determined as well as
the presence, absence and/or thickening of the cortical bone.
Goto et al. (2007)
No artefacts (Eggars et al. 2005) Cotti & Campisi (2004)
Inc
111

Cholesteric liquid crystals
Cholesteric crystals are a type of ‘liquid’ crystal, i.e. ordered fluids,
with a helical structure ordered along the long axis known as
chiral- nematic liquid crystals.
Due to their fluidity these are easily influenced by
temperature or pressure.
The pitch of the very structure of the crystal varies when the pressure
or temperature are altered thus changing their color heated i.e. they
are thermochromic.
When applied to the tooth surface, the crystals undergo color
changes that were compared with adjacent or contralateral-teeth
Inferences :
Vital Non Vital
blue green Red
Red Green Yellow
Green Yellow red
112

• 3D volume of data is acquired in the course of a single sweep
of the scanner, using a simple, direct relationship between
sensor and source, which rotate synchronously
through 180–360 around the patient’s head.
• The X-ray beam is cone-shaped (hence the name of the
technique) and captures a cylindrical or spherical volume of
data, described as the field of view
• The size of the field of view (FOV) is variable, large volume
CBCT scanners (for example, i-CAT; Imaging Sciences
International, Hatfield, PA, USA and NewTom 3G, QR,
Verona, Italy) being capable of capturing the entire
maxillofacial skeleton.
• Some CBCT scanners also allow the height of the cylindrical
field of view to be adjusted to capture only the maxilla or
mandible
CBCT
Tyagi SP, Sinha DJ, Verma R, Singh UP. New vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90
113

Based on tomosynthesis (Webber & Messura 1999).
A series of 8–10 radiographic images are exposed atdifferent
projection geometries using a programmable imaging unit, with
specialized software to reconstruct a three-dimensional data set
which may be viewed slice by slice
Diagnostic accuracy of TACT was superior to conventional two-
dimensional radiography for the detection of vertical root
fractures(Nair etal 2001,2003)
Complex nature of the adjacent anatomy around posterior
maxillary molar teeth limits the use of TACT(Barton et l 2003)
The resolution is reported to be comparable with 2D radiographs
(Nair & Nair 2007).
TACT is more diagnostically informative and had more impact on
potential treatment options than conventional radiographs Cotti &
Campisi 2004, Nair & Nair 2007, Patel et al.
2007).
TACT
Tyagi SP, Sinha DJ, Verma R, Singh UP. New vistas in endodontic diagnosis. Saudi Endod J 2012;2:85-90
115

• Given radiographs taken in precisely the same position
and with the same beam geometry and exposure parameters,
images can be subtracted to show changes over
time.
• Major drawbacks include difficulties experienced
in practice in achieving images with reproducible projection
geometry over time.
DIGITAL SUBTRACTION
RADIOGRAPHY
116

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Bellizzi R, Drobotij E, Keller D, Kenevan R. Sinusitis secondary to pregnancy
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Chelm-Berger D, Gutmann JL. Focal myositis mimicking posttreatment pain
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