This document discusses various chair-side investigations in dentistry. It covers tests for hard tissue examinations like dental caries detection using methods like fiber-optic transillumination, quantitative light fluorescence, and laser autofluorescence. It also discusses pulp vitality tests including thermal tests, electric pulp testing, and advanced tests like laser Doppler flowmetry. Further, it covers investigations for periodontal diseases, trauma from occlusion, mobility testing, and plaque disclosure agents.

1. CHAIR-SIDE INVESTIGATIONS
PRESENTED BY: DR. STUTEE BERIWAL
PG 1ST YEAR
ORAL MEDICINE & RADIOLOGY

2. 1. Investigations for Hard Tissue Examinations
2. Test for Periodontal diseases.
3. Test for detection of vascular lesions.
4. Test for detection of potentially malignant lesions and conditions
5. Investigation for Maxillary sinus
6. Investigation for Saliva and Taste evaluation
7. Lacrimal test
8. Investigation for allergy
9. Investigation for TMJ and muscles of mastication
10. Investigation for Neuromuscular disorder
11. Miscellaneous

3. 1. Investigations for Hard Tissue Examinations

4. Diagnosis of Dental caries:
Conventional methods
• Tactile exploration
• Visual examination
• Dyes
Advances
Visible light
• Optical caries monitor
• Quantitative fiber-optic transillumination (FOTI)
• Digital Image fiber-optic transillumination (DFOTI)
• Quantitative light/laser-induced fluorescence (QLF).
Laser light
• DIAGNOdent - Laser autofluorescence.
Electrical current
• Electrical conductance measurement
• Electrical impedance measurement.
Ultrasound
• Ultrasonic caries detector.

6.  Visible light
o Optical caries monitor
• Principle used is that in white spot carious
lesion, scattering is stronger than in sound
enamel surface
• Light is transported through a fiber bundle
to the tip of handpiece. Tip is placed
against the tooth surface and reflected
light is collected by different fibers of the
same tip

10. Mechanism of action
• It uses safe white light in which receptor with photocells converts photon energy
to electrical energy and converted into color value and displayed on video
monitor.
• When the teeth are transilluminated, areas of demineralized enamel or dentin
scatter light and incipient caries appear darker in the resultant image.
• Useful for comparative examinations of the same tooth over time.

13. Quantitative laser-induced fluorescence
Fluorescence results from change in the characteristics of light caused by a
change in wavelength of incident light rays following reflection from the surface
of material.
 Recently, it has been found that bacterial metabolites within caries produces
fluorescence that can be enhanced by laser light.
 It provides a fluorescent image of a tooth surface within yellow-green
spectrum of visible light that quantifies mineral loss and size of the lesion.
 Most important parameters produced by QLF are lesion area, depth, and
volume

17. Laser Autofluorescence-
Diagnodent

18.  Laser Light
DIAGNOdent - laser autofluorescence
• DIAGNOdent technology uses a simple laser diode to compare the reflection wavelength against a well-known
healthy baseline to uncover decay.
• When the device operates, healthy tooth structure exhibits little or no fluorescence, resulting in very low scale
readings on the display. Carious tooth structure exhibits fluorescence proportionate to the degree of caries,
resulting in elevated scale readings on the display.
• First, the laser diode is aimed at the healthy enamel tooth structure to obtain a benchmark reading. After
calibration, it is moved to inspect all the surfaces of the teeth, shining the laser at 2.5 mm into all suspected areas.
• As the laser pulses into grooves, fissures, and cracks, it reflects fluorescent light with particular wavelength. This is
because light is absorbed by the organic and inorganic components of the tooth which induce infrared
fluorescence.
• This fluorescence is collected at the top of handpiece and transmitted back to the DIAGNOdent unit. Light is
measured by receptors, converted into an acoustic signal, and evaluated electronically to reveal values between 0
and 99

19.  Electric Current
o Electrical conductance measurement
• Electrochemical machining (ECM) is based on the principle that a
demineralized tooth has more pores filled with water or saliva, and this is
more conductive than intact tooth surface.
• Greater the amount of demineralization, higher is the electrical conductivity
through enamel. Demineralized sites and sites with high pore volume and
cavities can be detected by measuring the conductance.

20. o Vanguard electronic caries detector
• It uses a current of 25 Hz. Measured
conductance was then converted to an
ordinary scale of 0-9.
o Caries meter
• It uses a current of 400 Hz. Measured conductance was then converted to
four colored lights.
• Green: No caries
• Yellow: Enamel caries
• Orange: Dentin caries
• Red: Pulpal involvement.

21. Electrical impedance measurement
• Electrical impedance measurement is a measure of degree of resistance to the
flow of electric current.
• Caries tissue has a lower impedance than sound tooth. It is also known as
electronic caries monitor.

22. Ultrasound Caries Detector
• Ultrasound makes the use of sound waves with frequency > 20,000 Hz
• For sound waves to reach the tooth, various acoustic coupling agents have been
used such as mercury, aluminum rods, water, and glycerin.
• An ultrasonic probe is used which sends and receives longitudinal
waves to and from the surface of the tooth.
• Initial white spot lesions produce no or weak surface echoes,
whereas sites with visible cavitation produce echoes with
substantial higher amplitude.

24. A. PULP VITALITY TESTS: Assess the status of pulp.
1. Thermal test
a. Cold test
b. Heat test
2. Electric pulp testing
3. Other tests
a. Pulse oximetry
b. Test cavity
c. Selective anaesthesia
d. Laser Doppler flowmetry
e. Photoplethysmography
f. Dual wave length Spectrophotometry
g. Surface temperature measurement

25. b. HEAT TEST Mechanism:
Heat thermal testing causes expansion of the dentinal fluid within the
dentinal tubules
Resulting in a rapid inward flow of fluid within the patent tubules
This rapid movement of dental fluid results in ‘hydrodynamic forces’
acting on the Aδ nerve fibres within the pulp- dentin complex
Leading to a sharp sensation lasting for the duration of the thermal test

27. Advantage:
 Accurate response.
Disadvantages:
 This test may be difficult to use on posterior teeth because of limited access.
 Excessive heating may result in pulp damage.
 Prolonged heat application will result in bi-phasic stimulation of A δ fibres initially, followed by the
pulpal C fibres.
 Activation of C fibres may result in a lingering pain, therefore heat tests should be applied for no
than 5s. However, inadequate heating of the gutta-percha stick could result in the stimulus being too
weak to elicit a response from the pulp.

28. a. COLD TEST:
Mechanism:
Cold thermal testing causes contraction of the dentinal fluid within the dentinal tubules
Resulting in a rapid outward flow of fluid within the patent tubules
This rapid movement of dental fluid results in ‘hydrodynamic forces’ acting on the Aδ nerve fibres within
the pulp- dentin complex
Leading to a sharp sensation lasting for the duration of the thermal test

32. 2. ELECTRIC PULP TEST:
 It is based on stimulation of sensory nerves, and relies on subjective assessments and comments
the patient.
 This test relies on electric impulses directly stimulating the nerves especially A-delta sensory nerves of
the pulp. Electric pulp tester checks the status of the nerve fibres.
Factors affect the response are :
 Enamel thickness
 Probe placement of the tooth
 The cross sectional area of the probe tip
 Interfering restorative materials.
 Patient’s level of anxiety.
 Selective medications.
 Recently traumatized tooth

33. Procedure:
 Teeth are isolated and dried with cotton balls.
 The tip of the electrode is covered with toothpaste or a similar electrical conductor.
 To complete the circuit, patients should place a finger on the handle of the device or a lip clip can be used .
 Multirooted teeth may need to be tested by placing the electrode on more than one location on the crown.
 The electrode should be applied to the dried enamel at middle third of the facial surface of the crown (currents of 5-20 ma are
used)
 The current flow should be slowly increased till the tingling or warm sensation is felt.
 EPT should be used at least 2 to 3 times on each tooth and an average result should be recorded.
 The readings from the pulp tested should be recorded and compared with the normal adjacent tooth.

34. A false positive response: Pulp is necrotic, but the patient feels sensation in tooth
Reasons:
Moist gangrenous pulp is present in root canal.
Multirooted teeth with partially necrotic pulp.
Improper isolation
Patient anxiety
Proximal metallic restoration (transfers stimulus to adjacent tooth)
A False negative response: Pulp is vital ,but the patient does not complain of sensitivity.
Reasons:
Calcified pulp chambers.
Teeth with extensive restorations and protective bases.
Recently traumatized tooth.
Recently erupted tooth with incomplete root formation
Patients with unusually high pain threshold
Patients on sedatives or alcohol
Inadequate conductor media.
Low battery
Patients with psychotic disorder

35. Limitations :
 EPT fails to provide any information about the vascular supply or histological status of the pulp. It
provides only a responsive or non responsive result
 They may be frightening to the patients, and can elicit a response from the periodontium.
 Should be used with precaution in patients with cardiac pacemakers
 They are not recommended for use on crowned teeth or in patients wearing orthodontic bands.

36. TEST CAVITY PREPARATION
 It is only considered when the results of all other tests have proved inconclusive.
 The test cavity is made by drilling through the enamel–dentine junction of an
tooth with good isolation.
 This may be achieved under rubber dam with a small round diamond bur in a high-speed
handpiece with adequate coolant.
 The patient is asked to respond if any painful sensation is felt during the drilling procedure.
 If the patient feels pain or sensitivity once the bur contacts the sound dentin, the procedure is
terminated and cavity is restored; in case of no response, endodontic treatment can be
continued.

37. LOCAL ANAESTHETIC TEST
 When dental symptoms are poorly localized or referred, an accurate diagnosis is extremely difficult. Sometimes,
patients may not even able to specify whether the symptoms are from the maxillary or mandibular arch. In such
cases, and where pulp testing has proved inconclusive, an anaesthetic test may be helpful.
 The technique is as follows: using either infiltration or an intraligamentary injection, the most posterior tooth in
area suspected of causing the pain is anaesthetized.
 If pain persists once the tooth has been fully anaesthetized, the tooth immediately mesial to it is then
and so on, until the pain disappears.
 If the source of the pain cannot be even localized to the upper or lower jaw, an inferior alveolar nerve block
injection is given; cessation of pain indicates involvement of a mandibular tooth. This approach has an advantage
over a test cavity, which may incur iatrogenic damage

38. Laser Doppler Flowmetry
The aim of this technique is to objectively measure the true vitality of the pulp non invasively. LDF
can reliably differentiate between healthy and non-vital teeth
This electro-optical technique uses a laser source that is aimed at the pulp, and the laser light
travels to the pulp using the dentinal tubules as the guide.
Photons that interact with stationary elements are scattered but are not Doppler shifted.
The backscattered reflecting light from the circulating blood cells is Doppler-shifted and has a
different frequency to the static surrounding tissues.
Because red blood cells represent the vast majority of moving objects within the tooth pulp,
measurement of Doppler-shifted backscattered light is interpreted as an index of pulpal blood
It is generally agreed that LDF assessment for human teeth should be performed at 4 weeks
following the initial trauma, and repeated at regular intervals up until 3 months.

39. PULSE OXIMETRY
 Pulse oximetry is an entirely objective test.
 The pulse oximeter sensor consists of two light-emitting diodes, one to transmit red light (660 nm)
the other to transmit infrared light (940 nm), and a photodetector on the opposite side of the vascular
bed.
 The light emitting diode transmits light through a vascular bed such as the finger or ear. Oxygenated
haemoglobin and deoxygenated haemoglobin absorb different amounts of red/infrared light.
 The pulsatile change in the blood volume causes periodic changes in the amount of red/ infrared light
absorbed by the vascular bed before reaching the photodetector.
 The relationship between the pulsatile change in the absorption of red light and the pulsatile change
the absorption of infrared light is analysed by the pulse oximeter to determine the saturation of
blood

40. PHOTOPLETHYSMOGRAPHY
 Is a simple optical technique used to detect volumetric changes in blood in peripheral circulation
 It is low cost and non invasive
PRINCIPLE
 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 tooth.

41. Transmitted light photoplethysmography (TLP)
 TLP is a non-invasive technique used to monitor pulpal blood flow.
 It has been suggested that TLP incurs less signal contamination from the
periodontal blood flow than is the case for Laser Doppler flowmetry.

43. 1. Test for Cracked tooth syndrome
2. Test for trauma from occlusion
3. Mobility test
4. Plaque disclosing agents
5. Periotemp
6. Periotest
7. Perioscopy

44. 1. Test For Cracked Tooth
Cracked tooth is defined as an incomplete fracture of the dentine and occasionally extends into the pulp
 Visual Inspection
 Tactile Examination
 Periodontal Probing
 Dye Test
 Transillumination
 Bite test

45. Transillumination
• Important aid in locating crack , the tooth should be cleaned & light source should directly on the
teeth
• Transillumination with fibre optic light and use of magnification will aid in visualisation of a crack
• Cracks will block the light beam from reaching the part of the tooth beyond the fracture, whereas
sound tooth will transmit light throughout the crown.
Bite Test
• It is performed using orange wood stick, cotton wool rolls, rubber aversive wheels or tooth sloth
fracture detector.
• Placed on the cusp of the tooth and ask the patient to bite down with moderate pressure and then
release.
• Pain during releasing of bite pressure is seen in cracked tooth syndrome.

46. 2. Test For Trauma From Occlusion
Fremitus Test / Functional Mobility
 Fremitus is the measurement of vibratory pattern of the teeth when teeth is placed in contacting
position and movements
 Wet the ungloved finger and place it partially on the gingiva and partially on teeth and ask the
patient to bite repeatedly.
 Observe the vibration produced in lateral protrusive movements.
 The following classification system is used ;
• Class 1 fremitus – mild vibration or movement detected
• Class 2 fremitus-easily palpable vibration but no visible movement
• Class 3 fremitus – movement visible with naked eye

47. 3. MOBILITY TEST
 Movement is usually measured by applying direct pressure to
individual teeth using a dental instrument.
 In order to accurately evaluate mobility, two non working end
of the dental instruments are pressed on the buccal and
lingual surface of the teeth
 Another method involves placing a finger on the front surface
of the tooth and feeling for the movement while the patient
grinds or chew
 Grades:

48. 4. PLAQUE DISCLOSING AGENTS:
 Disclosing agents are used for identification of dental plaque which may be invisible to the naked eye
 When applied to the teeth the agent imparts it colours to the soft deposits but can be rinsed easily
from the clean tooth surface
USES OF DISCLOSING AGENT :
 Diagnosing and demonstrating the dental plaque to the patient
 personalised patient instruction and motivation
 Self evaluation by the patient to evaluate the effectiveness of oral hygiene maintenance

49. 1. Iodine preparations
2. Mercurochrome preparations
3. Bismark brown
4. Merbromin
5. Erythrosine
6. Fast green
7. Fluoroscein
8. Two tone solution ( stains older plaque blue and newer red)
9. Basic fuchsin.
10. Buckley’s solution
11. Berwick’s solution
12. Talbot’s solution
13. Iodo-glycerol solution
14. Metaphen solution
15. Allura red

50. MECHANISM OF TWO-TONE DISCLOSING AGENT:
 A two-tone disclosing agent comprises of a combination of erythrosine with either green or
blue shade to obtain differential staining i.e. old plaque stains blue and thin new plaques
stain red
 The red and blue colour is because of the newer plaque has acidic and the older plaque has
the basic environment.

51. METHODS OF APPLICATION
I. Solution for direct application (painting):
II. Rinsing
III. Tablets/wafers
INTERPRETATION OF FINDINGS:
a. Clean tooth surface do not absorb the colouring agent. When pellicle and bacterial
plaque are present, they absorb the agent and are disclosed.
b. Pellicle stains as a thin relatively clear covering, whereas bacterial plaque appears
darker, thicker and more opaque.

55. Test for detection of vascular lesions.

56. Diascopy
Simple blanch test performed with minimal equipment and is a quick tool for
proper diagnosis.
Principle
Its based on the principle that vascular lesions will blanch in response to
pressure with the glass slide
This procedure aims at emptying the blood from the superficial vessels to
determine whether the colour of the lesion is due to blood present in the
or extravasated blood present in the tissue

57. Indications
Is an essential requirement on an coloured
lesion. Helps to differentiate vascular
from a non vascular pigmented lesion
It can be used to detect the glassy brown
appearance seen in papules of sarcoidosis
tuberculosis , and other granulomatous
lesions
Before carrying out any biopsy or excision
of pigmented in oral cavity or skin to
any intraoperative complication due to
blood over flow from the vascular lesion

58. TOURNIQUET TEST
 This determine the capillary fragility , to determine the
haemorrhagic tendency
 A tourniquet is a device that is used to apply pressure to
limb or extremity in order to limit – but not stop – the
of blood
 Is performed by inflating the blood pressure cuff to a
point mid way between the systolic and diastolic pressure
for 5 min.
 The test is considered positive when 10 or more
per inch are observed

59. Test for detection of potentially malignant lesions
and conditions

60. A) Vital Staining
Toluidine blue staining
Lugol’s iodine
Methylene blue
Rose Bengal
Acetic acid staining
B) Light Based Detection System
Tissue fluorescence imaging
Chemiluminescence
Narrow band imaging
C) Cytological Technique
Oral brush biopsy
Exfoliative cytology
FNAC
D) Histological Technique
Incisional biopsy
Excisional biopsy
Punch biopsy
E) Colposcopy/Fluoroscopy test

61. A) Vital Staining
 Vital staining is the clinically visible aid that can be used routinely to assist the site of biopsy, follow up
of premalignant lesions and marginal demarcation of the malignant lesions enables an intervention
method to be adopted earlier for the diseases, which carries a high rate of morbidity and mortality .
 Rationale:
Vital staining is a procedure where living cells take up certain dyes, which selectively stains some
in the cells like mitochondria, lipid vesicles, lysosome, etc. resulting in differential uptake of the dye.
 It is of two types:
1. Intravital staining (in vivo)
2. Supravital staining (in vitro)

62. TOLUIDINE BLUE (TB) STAINING
 Toluidine blue is also known as tolonium chloride, methylanaline, aminotoluene.
 Toluidine blue is an acidophilic metachromatic dye which has the ability to bind to acidic tissue
components, thereby it binds to the nuclear material of the tissues having high DNA and RNA content
 To reduce the toxicity of these stains they are used in dilute solutions ranging from 1:5000 to 1:500000.
 Sensitivity and specificity was found 100%.
Principle
 As the toluidine blue has the ability to bind to acidic components of the tissue, it is based on the fact
that dysplastic and neoplastic cells contain more nucleic acid quantitatively than normal cells. Also the
intercellular canals are wider in malignant epithelium than the normal epithelium, thereby enhancing
the penetration of dye.
 For intraoral use, 1% of toluidine blue is used.

63. Composition
100 ml of 1% TB contains 1 gm of toluidine blue powder, 10 ml of 1% acetic acid, 4.19 ml of
absolute alcohol and 86 ml of distilled water, pH maintained at 4.5
Procedure

64. Advantages
• It is inexpensive, simple procedure, screening high- risk patients who may have
asymptomatic malignant lesions of oral cavity.
• Helpful for surgeon in operating room to evaluate free surgical margins.
• Toluidine blue staining of oral epithelium will not interfere with histologic staining or
interpretation.
Disadvantages
• Both false positive and false negative results are more.
• Filiform papillae retain the dye due to high protein synthesis rate.
• It appears to stain only three to four cells deep and thus reflects changes in the
epithelial layer alone. Invaded underlying tissue is not penetrated by the dye. So the
extent of submucosal spread is difficult to appreciate.
• As the dye reacts with nucleic acid, there is a possible mutagenic effect of this stain
when vitally stained cells are exposed to high energy irradiation

65. False positive results are seen with following lesions:
 Epithelial hyperplasia, hyperkeratotic lesions, inflammatory and traumatic lesions, hyperplastic
candidiasis can retain 60% of stain.
 The decision making can also be attributed to the experience of the clinician.
Repeat the test after 10-14 days to allow the inflammatory lesions to resolve.
This reduces the false positive by 8.5%.
False negative results are recognized in Low grade dysplasia, lichenoid dysplasia

66. LUGOL’S IODINE STAINING
Other names for Lugol’s solution are I2KI (iodine– potassium iodide), markodine, strong solution
(systemic), aqueous iodine solution
Composition
• Iodine 2 g , potassium Iodide 4 gm in 100 cc of distilled water
Principle
 The principle is based on glycogen content of the cytoplasm and the reaction is known as the iodine–
starch reaction, visualized by a colour change.
 As there is enhanced glycolysis in cancer cells, do not promote the iodine–starch reaction. Hence
there is no color change in dysplastic epithelium, whereas due to high glycogen content of normal
epithelial cells, brown color can be noticed.
 The vital dye with Lugol’s solution is also called Schiller’s test.

67. Procedure:

68. ACETIC ACID STAINING
Composition
 100 ml of 1% acetic acid rinse contains 1 ml of glacial acetic acid with 99 ml distilled water.
Principle
 Application of acetic acid causes reversible coagulation / precipitation of cellular proteins and causes
swelling of the epithelial tissue, particularly abnormal squamous epithelial areas, dehydration of the
cells and it helps in coagulating and clearing the mucous secretions.
 The normal squamous epithelium appears pink and the columnar epithelium red, due to the reflection
of light from the underlying stroma, which is rich in blood vessels.
 If the epithelium contains a lot of cellular proteins, acetic acid coagulates these proteins, which may
obliterate the colour of the stroma. The resulting acetowhitening is seen distinctly as compared with
normal pinkish colour of the surrounding normal squamous epithelium.

70. ROSE BENGAL STAINING
 It can stain the desquamated epithelial cells.
 RB staining is used to delineate the extent of the oral epithelial dysplasia and OSCC.
Principle
 With an exposure for 1 second, it predominantly stains the cell membranes.
 An increasing the concentration or time of exposure, it produces predominant nuclear staining.
 A primary epithelial abnormality such as dysplasia, metaplasia, virus infected cells or other forms of
epithelial keratitis can render the inability of epithelium to interact with the mucous layer, thus
allowing the RB staining.

72. APPLICATIONS OF VITAL STAINS
 To highlight the potentially malignant oral lesions
 To identify early lesions which could be missed out on clinical examination
 To outline the full extent of dysplastic epithelium or carcinoma prior to excision
 To detect multicentric or second primary tumours
 Selecting the biopsy sample site in premalignant lesions
 Help in follow up the patients with oral cancer
 Useful in obtaining the marginal control of carcinoma
 Can be used as effective screening modality to assess the intra operative margins alterative to the
frozen sections
 Recognition of post-treatment recurrence
 Also in educating the patient

73. LIGHT BASED DETECTION SYSTEMS:
1. TISSUE FLUORESCENCE IMAGING :
 When oral mucosa is excited by a beam of blue-violet light (400-460 nm), it has a distinctive green-
apple color, and, if there was an alteration of the tissue fluorophores, mucosa exhibits a characteristic
loss of fluorescence.
 Loss of autofluorescence is believed to reflect the complex and progressive morphological and
biochemical changes, typical of squamous epithelial carcinogenesis.

74. 2. CHEMILUMINESCENCE:
Refers to emission of light from a chemical reaction
 Principle: based on reflectance phenomenon of target tissue area. Following application of
dehydration agent such as acetic acid, leukoplakic lesions are seen with changes in refractile
that occur in atypical nonkeratinized squamous cell epithelium due to increased nuclear: cytoplasmic
ratio.
 Absorbed by normal cells and reflected by abnormal cells having a higher nuclear-cytoplasmic ratio &
hyperkeratinisation.
 The appearance of an “aceto-white” lesion after
a one-minute rinse with 1% acetic acid solution is
considered as positive. The absence of such findings
is considered as negative (Rajmohan et al. 2012).
 High sensitivity and low specificity

75. 3. Narrow-Band Imaging(NBI)
 NBI is an optical image enhancement technique that improves the visibility of vessels
and other tissues on the mucosal surface.
 NB illumination is strongly absorbed by haemoglobin thus capillaries with the mucosal
surface are displayed in brown on the monitor while veins in the submucosa in cyan.
 Considered positive as scattered well-defined brown spots.
 NBI evaluation may increase the accuracy of detection of subclinical neoplastic
transformation.

81. Biopsy:
Biopsy is defined as the removal of tissue from living organism for the purpose of
microscopic examination and diagnosis.
Types:
 Incisional
 Excisional
 Punch
 Brush
 FNAC
Uses:
 Confirm the diagnosis
 Determine the extent or margin of the disease
 Rule out the possibility of malignancy
 Medico-legal record.

82. Indication:

83. Contraindication:

89. 5. Investigation for sinuses
i. Transillumination Test
 Performed in dark room
 High intensity light source placed inside the patient’s mouth or against the cheek for the maxillary
sinus and under medial aspect of supraorbital ridge for the frontal sinus
 if sinus contain excess fluid or a mass or a thickened mucosa the glow is decreased

90. 5. Investigation for Saliva and Taste evaluation
A) Collection Of Whole Saliva
a. Draining technique
b. Spitting
c. Suction methods
d. Parotid collector -Carlsson crittenden cup
i. Submandibular - Segregator
ii. Minor salivary gland –Periotron
B) Test for Xerostomia
i. Tongue blade sign
ii. Lip stick test
C) Test for detection of Taste disorders
i. Electrogustometry
ii. Whole mouth test/sip and spit method
D) Test for Oral malodour
i. Organoleptic method
ii. Gas chromatography
iii. Sulfide monitors
iv. Electronic nose
v. BANA test

91. Saliva flow
 The accepted flow rate of unstimulated saliva is anything above 0.1 ml per minute . For stimulated
saliva ,the accepted norm is 0.2ml per minute.
 On an average , the flow rate for unstimulated saliva is 0.3ml per minute with the average total of 16
hours of unstimulated flow being 300 ml
 Stimulated flow of saliva is 7ml per minute on average.
 Stimulated saliva is supposed to contribute as much as 80 to 90 % of the daily secretion
Saliva as a diagnostic tool :
 Besides its basic homeostatic function in the mouth saliva is a very important diagnostic fluid. The
reasons behind the usefulness of saliva in this regard are :
 Easy to collect
 Most non invasive fluid to collect
 Abundant in quantity to sample
 Does not need costly equipment for sampling

92. Whole saliva :
 Whole saliva is a mixture not only of glandular secretion but also contains bronchial ,nasal secretion,
GCF, food debris and cells
 The various methods of collecting whole saliva have been mentioned
• Draining method
• Spitting method
• Suction method
• Absorbent method
A commercially available absorbent method for the collection of whole saliva is the salivate method .
Using this method ,the saliva is collected by chewing cotton wool which is citric acid treated . Recovery of the
saliva is done by returning the soaked cotton to the salivate and centrifuging the container

93. Parotid Collector -Carlsson Crittenden Cup/Lashley Cup
 The inner chamber is attached to a rubber bulb or a suction device via a plastic tube and the cup is placed over
the stensons duct
 Parotid saliva is always collected in a stimulated state
Submandibular – Segregator:
 Schneyer et al have suggested the method of collecting submandibular and sublingual saliva .
 The custom made segregator has a central chamber for collection of submandibular saliva and 2 lateral
chambers for collection of sublingual saliva
 The collector is placed over the lower jaw and has to be custom made for the patient.
Minor Salivary Gland –Periotron :
 labial and buccal gland saliva
 Saliva from the minor labial and buccal glands is collected by paper strip method
 Either 2.2 x 4.4 mm periopaper strips or 6 x 16 mm pure chromatography paper strips are used and held with
cotton pliers on the sampling site to wet and collect the saliva

94. Test for xerostomia
Tongue Blade Sign:
 when the mouth is examined a tongue depressor may stick to the buccal mucosa.
Lip Stick Sign:
 Lipstick adhering to the front teeth may be a useful indicator for xerostomia

95. Test for detection of Taste disorders
ELECTROGUSTOMETRY
 It is the measurement of taste threshold by passing controlled anodal current through the
tongue
 When current passes through the tongue a unique and distinct metallic taste is perceived
 In 1990’s the Rion [TR-06] was developed, this is the only electrogustometer used for
diagnosis and research and is manually calculated.
WHOLE MOUTH TEST
 It is a simple gustatory test
 It can be applied easily and can be used to access overall taste which a subject is supposed
to be feeling
 For the detection of average threshold and recognition of the four basic taste, sweet, salt,
sour and bitter taste solution where made

96. TEST FOR ORAL MALORDOR
 Is considered a social problem
 The unpleasant smell of breath arises mainly from the volatile sulphide compounds especially
hydrogen sulfide, methylmercaptan , dimethyl sulphide
Intraoral causes
 Deep carious lesion with food impaction and putrefaction
 Extraction wounds filled with a blood clot, and purulent discharge leading to important putrefaction
 Interdental food impaction in large interdental areas
 Crowding of teeth
 Acrylic dentures
 Periodontal infection
 Dry mouth
 Tongue coatings

97. Extraoral causes
 Acute pharyngitis
 Purulent sinusitis
 Chronic sinusitis
 Regurgitation esophagitis
 Chronic or purulent Tonsillitis
 Foreign body in a nasal or sinus cavity
 Chronic bronchitis, bronchiectasis and bronchial carcinoma
 Zenker’s diverticulum [hernia in the oesophageal wall, allowing accumulation of food and
debris and thus putrefaction]
 Gastric hernia
 Intestinal gas production
 Liver cirrhosis [ammonium will be accumulated in blood and will be exhaled]
 Kidney insufficiency , primarily caused by chronic glomerulonephritis will increase the uric
acid level in the blood which is expressed in the expired air in the typical ammonium like
breath

98. Diagnosis Of Malodour
 Medical history
 Listen to the patient, and patient will tell you the diagnosis
Clinical and laboratory examination
Self-examination :
The following self testing can be used
 using a metallic or nondorous plastic spoon after scraping the back of the tongue.
 using a toothpick after introducing it in an interdental area .
 Using saliva spit in a small cup or spoon (especially when allowed to dry for a few seconds so that
odours can escape from the liquid .
 Analysing the tongue coating and interdental debris, two major causes of putrefaction ,will immediately
good insight on the possible intraoral causes

99. Specific Character Of Breath Odour
 A “rotten eggs" smell is indicative of Volatile sulfur compound’s
 A “dead mice” smell is associated with liver insufficiency; besides VSC’s, alphatic acids
accumulation
 A smell of “rotten apples” has been associated with unbalanced insulin depended diabetes
which leads to accumulation of ketones
 A “fish odour” can suggest kidney insufficiency characterised by uraemia and accumulation of
dimethylamine and trimethylamine

100. PORTABLE VOLATILE SULFIDE MONITOR
 The electronic device analyses the concentration of hydrogen sulphide and methylmercaptan.
 Examination should preferably done after atleast 4 hours of fasting and after keeping mouth closed
3 minutes
 The mouth air is aspirated by inserting a drinking straw fixed on the flexible tube of the instrument
 This straw is kept about 2 meter behind the lips , without touching any surface and while the subject
keeps the mouth slightly open and breaths normally
 The sulfide meter uses a volumetric sensor that
generates a signal when expose to sulphur containing gases
 Absence of breath malodour leads to readings of
100 ppb or lower
 Patient with elevated concentration of Vscs easily
reaches 300-400 ppb
 This device as only reveals sulfur containing gases.

101. GAS CHROMATOGRAPHY :
 This device can analyse air ,saliva or crevicular fluid for any volatile component .
 Elaborate gas chromatography is only available in specialized centers but is specially
useful for identifying nonoral causes
 Recently a small, portable gas chromatograph has been introduced ,which makes this
technique available for periodontal clinics
 It has the capacity to measure the concentration of the three key sulfides separately

102. ELECTRONIC NOSE
 The electronic nose was developed in order to mimic the
human olfaction
 It consists of arrays of sensors which are able to generate
electrical signals in response to either simple or complex
volatile compounds present in the gaseous sample
 Essentially e- nose consists of three major parts :
• Sample delivery system
• Detection system
• Computing system
 The cyranose 320 is a handheld “electronic nose “
developed by Cyrano sciences of Pasadena ,California

103. BANA TEST
 It is a chair side enzyme based assay which is used to
determine the proteolytic activity of certain oral anaerobes
that contribute oral malodour which are considered as active
H2SO4 producer
 Species specific
 P
.gingivalis
 T.denticole
 T.forsythus
 It is a test strip composed of benzoyl-DL-arginine-a-
naphthalamide and detects short chain fatty acid and
proteolytic obligate gram negative anaerobes which
the synthetic trypsin substrate and cause halitosis

104. Lacrimal function

109. Rose Bengal dye test:
Principal:
Detection of damaged epithelial cells due to reduced tear production.
Procedure:
One drop of 1% Rose Bengal solution from a saline-wetted Rose Bengal strip is
in each conjunctival sac.
Result:
Damaged corneal cells if present appears as dry spots during corneal staining.
Uses:
Diagnosing early stages of kerato-conjunctival syndrome.

111. ALLERGY TEST:
PATCH TEST:
• Patch test relies on the principle of a type IV hypersensitivity reaction.
INDICATIONS:
• To test oral contact allergies
• To test possible drug allergies

112. TMJ and Muscles of mastication

114. T-SCAN:
ASSEMBLY:
• The T’ Scan System is a dental device used to analyze tentative occlusal force that is recorded
intraorally by a pressure-mapping sensor.
• The system components include a sensor and support, a handle assembly, the system unit,
computer software and a printer.
• The sensor is the key component.
• The T-Scan allows the quantification of occlusal contact data by registering parameters such
as bite length as well as the timing and force of tooth contact, and stores the data on a hard
drive which can be played incrementally for data analysis in a time-based video.

116. Investigation for Neuromuscular disorder
DIGNOSTIC NERVE BLOCK
 Both Diagnostic & therapeutic uses.
 Muscle injection & nerve block injection
Muscle injection
 Helps determining the source of pain disorder and can provide therapeutic value too.
Eg; injection of LA into a myofascial trigger point can result in significant pain reduction
 In myofascial pain , the patient presents with the firm taut band of muscle tissue that is quite painful
to palpate this is known as trigger point and is responsible for producing referred pain .
 When referred pain is suspected , the trigger point can be injected with LA and referred pain is shut
down.

117. Sequence for trigger point injection:
1. The trigger point is located by placing the finger over the muscle and firm pressure is applied to locate
the tight band . The finger is moved across the band so that it can be felt to ‘’snap’’ under the pressure
of the finger . Once the band has been identified ,the finger is moved up and down the band until the
most painful area is located
2. The tissue over the trigger point is cleaned with alcohol . The trigger point is then trapped between
two fingers so that when the needle is placed into the area , the tight band will not move away
3. The needle tip is then inserted into the tissue superficial to the trigger point and advanced to the
depth of the tight band
4. Once the initial anaesthetic has been deposited , it is useful to ‘’fan’’ the needle tip slightly . This is
done by withdrawing the needle halfway , changing the needles' direction slightly and re-entering the
firm band to the same depth
5. Once the injection has been completed , the needle is fully withdrawn and a sterile gauze is held over
the injection site with slight pressure for 5 to 10 s to assure good haemostasis

119. Inj. Of masseter muscles
Inj.of sternocleidomastoid
Inj. Of temporalis muscle
inj. Of post.occipital muscles

120. NERVE BLOCK INJECTIONS:
For diagnosis, a short acting LA should be used without a vasoconstrictor
DENTAL BLOCKS :
 The common nerve blocks used are the inferior alveolar nerve block, the posterior superior
nerve block, the mental block, and infiltration blocks often administered in various areas of the
maxillary arch
 For eg : an inferior alveolar nerve block will completely eliminate any source of pain coming
from the mandibular teeth on the side of the injection . This block is useful in separating
dental pain from muscle or joint pain since it blocks only the dental structures
 This is very important diagnostic information when the patients chief complaint is toothache in
mandible, IANB will eliminate the pain, and if toothache is actually a referred pain , the block
will not change the pain

121. AURICULOTEMPORAL NERVE BLOCK
 The primary innervation of the TMJ is from
the auriculotemporal nerve, with secondary
innervation coming from the masseter and
posterior deep temporal nerves
 If TMJ is a source of pain, this nerve block will
quickly eliminate pain

122. Chair side investigation of Cranial nerves.
Importance:
To rule out any neurological pathologies, which might complicate the dental procedure.

124. Cranial nerves
 1 Olfactory – Smell
 2 Optic- Visual acuity

125.  CN III Oculomotor-
Function Eye movement Observation
Raises eyelid Observation
Pupil constriction Reaction to bright light
Analysis of diplopia :
Shield one eye with a transparent red shield
Object is moved from left to right ,up or down
Ask if He/she sees 1 or 2 object
Analysing nystagmus :
 Watch the patients eye while talking
 Ask to look at a definite point & move the point from
left to right & up to down
 Hold each end position for 5 sec & assess nystagmus

126.  CN IV Trochlear- Vertical eye movement (SO4)
 CN VI Abducent- Lateral movement of eyeballs(LR6)

127.  CN V Trigeminal
Sensory: Facial sensation: Touch, pain & temperature.
 Ophthalmic: Forehead, scalp, and cornea.
 Maxillary: Hard Palate, nasal cavity, maxillary teeth.
 Mandibular: Anterior 2/3rd of tongue, mandibular teeth
Examined for lesion like trigeminal neuralgia.
Motor: Muscles of mastication:
Examined for Myofascial pain dysfunction syndrome

128. Method of examination (sensory)
1. Corneal reflex:
 Using a cotton piece the cornea is teased.
 Normal response is a bilateral blink
2. Light touch:
Stimulated by : cotton wisp, graded Frey’s hair
 Ophthalmic div- forehead
 Maxillary div- cheeks
 Mandibular div- chin
3. Pain and temperature:
 Sharp object and cold tuning fork

129. Motor assessment :
Muscles of mastication
 Keep the mouth open against resistance
 Lateral excursive movements against
resistance
 Protrude mandible against resistance

130. Jaw jerk
The mandible is tapped at a downward angle at the chin while the mouth is slightly open
with patellar hammer
In response, the masseter muscles will jerk the mandible upward. Normally this reflex is
slight
However, in individuals with upper motor neuron lesions in the jaw jerk is pronounced.

131.  CN XII Facial
Sensory: Taste from anterior 1/3rd of tongue
Motor: Facial expression
Purpose of test :
 To detect any unilateral or bilateral weakness of facial muscles
 Detect impairment of taste
Method of testing :
Observation :
 Symmetry and asymmetry of face
 Nasolabial fold & wrinkle on forehead
 Ask the Pt to close the eyes , raise the eyebrows ,
blow out the cheek , whistle etc

132. Examination of taste :
 The four primary taste can be carried out by using sugar, salt , vinegar( sour) & quinine
(bitter)
 The side of the tongue is moistened by the test substance
 Ask the Pt to indicate taste by pointing
Secretomotor function :
 The flow of tears of two side can be compared by giving ammonia to inhale which will
result in tearing of eye
 The flow of saliva can be tested by keeping a spicy substance in the tongue & the tip is
raised to observe the sub maxillary salivary flow
Reflexes :
 Nasopalpebral reflex : tap on the nasopalpebral ridge will produce closure of both eyes
In bells palsy there is failure to close on the affected side

133. Rinne’s test :
 Strike a tuning fork gently , hold it near one external meatus & ask the Pt if
he can hear it
 Place it on the mastoid , ask if he can still hear it & instruct him to say “ now
when sound ceases , & keep it on the external meatus again . (normally the
note is still audible)
Interpretation :
 In middle ear deafness – the note is not heard
 In cochlear nerve lesion- sounds are reduced but air conduction is
better than bone conduction
 CN VIII Vestibulocochlear- hearing & balance
Test of hearing :
Observe if the patient turns one ear towards you
Evaluate hearing using a ticking watch , rub fingers together , whisper.

134. Weber ‘s test :
 The fork is place on the vertex
 Ask the Pt if he can hear the sound all over the head , in both ears or in one ear
 In nerve deafness the sound appear to be heard on the normal ear
 On chronic middle ear disease it is conducted to the abnormal ear
Test for vestibular function
 Observe equilibrium as patient walks or stand
 Observe abnormal eye movements
 Ask for-
• Dizziness
• Falling
• Nausea and vomiting

135. CN IX – GLOSSOPHARYNGEAL – Mixed
The glossopharyngeal nerve provides
sensory supply to the palate
special sensory fibres (taste) from posterior 1/3rd of tongue.
Assessment: [ 9th nerve]
Gag reflex or by touching the arches of palate (soft palate)
Examination of taste.

136. CN X- VAGUS- Mixed
Provides motor supply to the pharynx.
Purpose:
• To test the elevation of palate & contraction of pharynx
• To examine the movements of vocal cord
Method of testing: Observation
Notice the pitch and quality of voice
Notice difficulty in swallowing saliva
Ask the patient to speak:
The uvula should be observed before and during the patient saying ‘AAH’.
In normal cases, the palate should move symmetrically upwards and backwards, uvula in the
midline, and 2 sides of the pharynx contract symmetrically.

137. CN XI - ACCESSORY - PURE MOTOR
 Trapezius muscle is tested by asking the patient to shrug his shoulders against resistance
 Sternocleidomastoid muscle is tested by asking the patient to turn his head or move his head
against resistance.
Purpose of the test
 To detect Wasting and weakness
or bilateral or unilateral

138. CN XII ; HYPOGLOSSAL - PURE MOTOR
Function:
Control movements of tongue, hyoid bone and larynx during and after deglutition.
Purpose of the test –
 To detect wasting weakness and involuntary moments
 To examine the voluntary muscle control
Method of testing- ask the patient to protrude the tongue and observe for
 Reduction in size on affected side
 Restricted protrusion
 Deviation of tongue, atrophy and fasciculations.

139. THANK YOU