Diagnosis

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Diagnosis
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  1. ¬ Approximately how large is this lesion in relation to what is seen on this radiograph?
    Seltzer and Bender 1961, Experimental Lesions in Bone.

    A. Visualizing Bone Loss & Apical Periodontitis – (Seltzer & Bender,1961 Experimental Lesions in Bone, Part 1 & 2) (Bender,1982) several!

    • • Lesions in Cancellous bone can not be detected by x-ray.
    • • Lesions in Cortical bone CAN be detected by x-ray ONLY if there is perforation of the bone cortex, erosion from the inner surface of the bone cortex or extensive erosion or destruction from the outer surface.
    • • Inflammatory lesions CAN be seen on X-ray if the lesions erode the junction of the cortex and cancellous bone or perforate the cortex
    • • Early stages of bone disease cannot be detected.
    • • NO correlation between size of rarefied area on x-ray with the amount of tissue destruction.

    In this case, accurate size m to d,
  2. What evidence is there in the literature to support the use of direct digital radiography in diagnosis of apical pathosis?LAMYO
    • a. Film vs. digital – NSD in determination of length using Schick digital measurement tool and electronic digital caliper measurement off a film, Both within 1 mm of true instrument length in vitro – (Lamus, 2001 Evaluation of a digital measurement tool to estimate working length in endodontics)
    • b. Film vs. digital – Subjective clarity compared with respect to length and homogenicity of obturation, Enhanced digital was superior to original digital and E and F film. (Akdeniz, 2005 An ex vivo comparison of conventional and digital radiography for perceived image quality in root fillings)
    • c. Film vs. digital – NSD between Digital and film in detecting artificial periapical bone lesions. (Mistak, 1998 Interpretation of periapical lesions comparing conventional , direct digital, and telephonically transmitted radiographic images)
    • d. Film vs. digital – NSD in detecting artificial periapical lesions in cortical bone. RVG superior in detecting lesions involving lamina dura and medullary bone – (Yokota & Newton 1994 –Interpretation of periapical lesions using RVG)
    • e. Film vs. Digital – NSD in length determination, in vivo comparison – (Ong & Pitt Ford, 1995 Comparison of Radiovisiography with radiographic film in root length determination)
    • f. 80 – 90% radiation reduction
  3. What diagnostic tests would you perform?
    Clinical tests: percussion, palpation. periodontal probings, mobility. Rule out Non- odontogenic pain, CO2 thermal tests to rule out adjacent teeth.

    Diagnostic tests donot give us a definitive diagnosis. Most tests do not actually access the vitality ( blood circulation) of the pulp and most do not give much in any indication about the presence or severity of inflammation in the pulp. The Main reason for doing pulpal tests are to reproduce symptoms, to localize the symptoms and to access the severity of symptoms.

    • There is a poor correlation between clinical symptoms and pulpal histopathology.And likely inaccurate!
    • Responses are Subjective and can be under or overstated (Eli, 1993 Dental anxiety: A cause for possible misdiagnosis of tooth vitality)
    • Responses are subjective and likely overstated ST

    • Seltzer & Bender, 1963 The Dynamics of Pulp Inflammation: Correlations between diagnostic data and actual histologic findings in the pulp.

    • Tyldesley & Mumford, 1970 (Dental pain and the histologic condition of the pulp) Classic: Examined 142 teeth with pain. No correlation between histology and clinical symptoms.

    • Schindler, Heat test – used on refractory cases to identify missed canals or late stage of an irreversible pulpitis

    • Garfunkel, 1973 Dental Pulp pathosis: Clinicopathologic correlations based on 109 cases.


    Senia, Cunningham, 1985 The diagnostic dilemma of barodontaliga. Report of two cases. Barodontalgia – sensitivity or pain caused by exposure to a pressure gradient. Fliers & Divers
  4. Thermal tests
    These tests are thought to work by hydrodynamic forces in the dentin initiating generator potentials in the nerve endings of displaced surface membranes. By this theory, fluid movement in the tubules (due to thermal stimulation) is responsible for activation of sensory receptor units in the pulp. (Brannstrom 1972 The Hydrodynamics of Dentine ;it’s possible relationship to dentinal pain).
  5. Cold Tests FSP
    • The most effective cold tests are those with CO2 (-78°C) and DDM (diflurochlormethane) (-50°C) (Fuss, Trowbridge 1986)Older techniques using refrigerator ice or ethyl Chloride (-4°C)are less reliable.
    • Potential for extreme cold to cause crack in dentin or irreversibly damage the pulp have been shown to be unfounded (Ingram, 1983, Rickoff, Trowbridge, 1988)

    Abnormal but positive responses are equally distributed among pulps of teeth in all diagnostic categories. (Seltzer & Bender, 1963 A positive response is an indication that the pulp is vital but does NOT indicate if the inflammation is irreversible. A negative response is highly indicative of necrosis. Seltzer & Bender, 1963.
  6. CO2 has advantage over other sensitivity tests
    in that it can be used with metallic and porcelain restorations, ortho bands, metallic splints, temporary and permanent crowns, It is the MOST effective vitality test for immature teeth. (Fuss, Trowbridge 1986 and Fulling, Andreason, 1976, Ehrman 1977
  7. Accuracy of Cold tests
    • (Petersson,1999)
    • 90% accurate!
    • Probability of negative test being necrotic pulp: 89% cold test, 88% EPT and 48% hot test
    • Probability of positive test being vital pulp: 90% cold test, 84% EPT and 83% hot test
  8. What is the probable source of infection?
    Coronal leakage Bacteria in root from initial tx or outside in PA area. Tronstad and Trope
  9. Based on the literature, describe the organisms that might be present in this case.
    • ► Untreated case FEPPPPLAVSTT GRAM NEGATIVE ANEROBES
    • ► Treated case FEEPPPLASSC GRAM POSITVE ANEROBES
    • Sundqvist & Figdor 2004
  10. Is it more difficult to obtain anesthesia in the presence of infection?
    YES. ACID pKa increase changes disassociation curve
  11. The patient indicates that she has a temperature of 101ºF. What role does fever play in the host’s response to infection?
    Increased temperature kills temperature sensitive bacteria
  12. What are the considerations regarding the choice of local anesthetic? What route of administration would you use?
    lido or carbocaine depending on if pt has any medical conditions which make her sensitive to epinephrine, IAN, PDL AND INTRAPULPAL.
  13. Describe the technique for administration of the Gow-Gates block and the nerves anesthetized.
    10 mm higher than IAN and toward tragus of ear. Gets long buccal, lingual and IAN.
  14. The general dentist treating this patient indicates that a Sargenti paste was used as a sealer. What evidence is there to refute the use of this material?
    Cytotoxic and leaves fixed antigenic material.

    • Newton 1980 cytotoxicity
    • Spangberg 1974 neurotoxic
  15. How should this case be treated?
    Initiate NSRCT with I and D clindaymicin, advil and Vicodin. Per Baumgartner; Clindamycin 98% effective, Augmentin 100% and Penicillin 85%
  16. What evidence is there in the literature regarding the use of CaOH as an intracanal medication?
    Lots, bactericidal and effective in 2 appointments but you can get same bacterial reduction in 1 visit with NaOCL. CAOH could against Endotoxin. Should be used in 2 visits not in one. No difference in healing rates. Waltimo 2005, Peters 2004 , studies say there is no difference in healing
  17. Is chloroform safe for use in retreatment procedures? Justify your answer using the literature.KMM (KIM)
    • 1. Kaminski 1998 JOE – No health risk to the patient, amount expelled thru the apex (0.32mg) is several orders of magnitude below the permissible toxic dose (49mg/m)
    • 2. McDonald 1992 JOE – Chloroform is safe for the dentist and staff. Air vapor levels were well below the OSHA mandated levels.
    • 3. Margelos,1996 - Chloroform uptake by gutta-percha and assessment of its concentration in air during the chloroform-dip technique. Concentration levels of chloroform evaporated during the practice of chloroform dip within a dental office do not exceed the safety limits.
  18. CHLOROFORM CONE FIT MVNK (MINK)
    • Moyer, 1995 - Evaluation of a solvent-softened gutta-percha obturation technique in curved canals. A significant difference in favor of the solvent-softened techniques was found over untreated lateral condensation.
    • Van Zyl, 2005 - Effect of customization of master gutta-percha cone on apical control of root filling using different techniques: an ex vivo study. Root filling extrusion was significantly influenced by 'operator' and was reduced by cold lateral compaction and customization of the master cone. Customization of master cone was the only factor that reduced voids apically.
    • Narracott,1989 - An in vitro comparison of the single cone and lateral condensation techniques using 'friction-fitted' and 'solvent dip-fitted' primary gutta-percha cones. The single cone and lateral condensation techniques which utilized chloroform dip-fitted cones ranked first and second with respect to frequency of no dye penetration
    • Keane & Harrington (1984) - The use of a chloroform-softened gutta-percha master cone and its effect of the apical seal. Described technique. Primary cone is 1–2 sizes larger than the apical preparation and selected to bind at 1-mm short of the working length. The apical 2 mm of the GP cone was dipped in chloroform for 1 second and the softened GP cone was gently placed into a slightly moist canal, noting the orientation of the cone. The GP cone was pushed to the canal terminus in a pumping motion and this was continued for another 10 s to allow the GP to become firm without engaging undercuts
  19. During treatment the patient loses consciousness. What are possible etiologies? How would you manage this situation? Syncope, MI, Stroke, acute adrenal insufficiency, diabetic coma or insulin shock, seizure epileptic or LA OD
    Basic ABC oxygen, reassess, 911, sugar, CPR
  20. The patient calls the next day and reports that her lip is still numb. What would you do?
    Monitor and reassure. Likely irritation to IAN , could also be pressure anesthesia from abscess.
  21. During retreatment a nickel-titanium file separates in the mesial lingual canal. What methods are advocated to retrieve the instrument?
    Scope, ultrasonics. Spili 2005 NSD in healing. Sabeti/Simon 2006 PA lesions healed without obturation. NSD fill or empty, so obturation may be overrated. A broken instrument may of no consequence, if you’ve adequately instrumented and disinfected.
  22. This patient has a history of malignant hyperthermia. Would you alter your treatment in any way?
    No, this is a concern with general anesthesia only
  23. What anesthetic / analgesic / antibiotic would you prescribe?
    Clindamycin 96% effective and not allergenic, ibuprofen 400 mg q6h 2 days, Vicodin prn pain
  24. What recall sequence? ONE YEAR RRO Reit, Rud & Orostavik
    • • Reit (1987): Decision strategies in endodontics: on the design of a recall program. Best recall is at one year. Also rec recalls annually for minimum of 4 years (esp in questionable cases)
    • • Rud & Andreasen (1972): A follow-up study of 1,000 cases treated by endodontic surgery. If PARL healed at 1 year, then ok
    • • Orstavik (1996): Time-course and risk analyses of the development and healing of chronic apical periodontitis in man. ~76% of apical periodontitis lesions developing post-tx are seen within 1year. Therefore, 1yr follow-up predicts long-term success.
    • I do 6 months but lit suggests 1 yr is optimum for healing or appearance of PAR.
  25. Based on the literature discuss the success rates for retreatment procedures and compare these to the success rates for initial root canal treatment. Outcome StudiesInitial treatment – NS RCT
  26. Re-treatment
  27. Surgical Root Canal Treatment
     
  28. The Toronto Studies – Outcomes
    • Initial treatment – confirmation that preexisting apical periodontitis and treatment technique were the main predictors of outcome in initial treatments.
    • a. overall healed rate for Phase I & II was 85%
    • b. if based on only radiographic measure it would be 95%
    • i. therefore, it should be noted that the absence of symptoms is insufficient as a measure of healing.
    • c. W/out preop AP healing rate reached 94%
    • d. With preop AP healing rate 79%
    • i. 45% showed reduced size from original
    • e. 10% higher healing rate noted for those cases treated with flared canal preparations and vertical compaction of warm gutta-percha than step-back preparation and lateral compaction of gutta-percha
    • f. Other factors were noted but not statistically significant – tooth location, preop symptoms, perio condition, flare-ups, final restoration.
  29. *Trope suggests that 3 factors effect outcome of perf treatment
    1. size, 2. location 3. time since perforation
  30. Toronto Study Surgical Retreatment
    – This study suggests that preoperative lesion size and root-filling length were significant predictors of outcome of apical surgery.

    • a. overall healing rate was 74%
    • b. 91% of the teeth were asymptomatic and functional
    • i. despite radiographic findings
    • c. 60% demonstrated reduction of lesion size, & asymptomatic
    • d. if reduced lesion size were included in healing overall = 87%
    • e. healing rate for long or short fills = 86%*
    • f. healing rate for adequate fills = 68%
    • g. healing rate for lesion < 5mm = 86%
    • h. healing rate for lesion > 5 mm = 65%
    • i. healing rate w/ orthograde retx = 84% (NSD)**
    • j. Retrograde retreatment healing rate 94%
    • *Lustmann suggests etiology removed therefore healing
    • ** Zuolo et al – 90% success for surgical cases previously retreated
  31. Based on the literature what are the anatomic and morphologic variations of this tooth group?
    8 types per Vertuccci 2 or 3 roots, mesial root 1, 2,1/2 2/1 2/1/2, 1/2/1
  32. Discuss the pros and cons of culturing this case. What would you do in your practice?
    Antibiotics sensitivity test delays initiation of therapy. Rx. Clindamycin 98%effective per Baumgartner against endodontic micro-organisms. She’s allergic to Penicillin which is 85% effective, so can’t take Augmentin ( Amoxicillin with Clauvulanic Acid) which is 100% effective.
  33. Electric Pulp Tester (EPT)
    • 1. EPT uses electric current to stimulate the sensory nerves of the dental pulp (Seltzer & Bender, 1985) specifically the fast conducting myelinated A delta fibers the pulp dentin junction.
    • 2. The unmyelinated C-fibers may (Mumford, 1967 Evaluation of GP and Ethyl chloride in pulp testing) or may not respond. (Nahri, 1979).
    • 3. Measurement of electric voltage may be inconsistent due to thickness of enamel & dentin, dryness, electrical resistance (Mcgrath, 1983), infraction, restorations, pins, fissures and cracks.
  34. A positive response to EPT is an indication of vital pulp tissues in the coronal aspect of the root canal space.
    But it is NOT an indication of the reversibility of the inflammation with the pulp. No correlation has been found between the pain threshold and the condition of the pulp. A negative EPT response was found by (Seltzer & Bender 1963) to indicate total necrosis in 72% and localized necrosis in 25.7%.of teeth tested. This means 97.7%. of mature teeth with negative EPT or partially or totally necrotic and need endodontic tx.
  35. Young pulps (teeth with open apices) respond unreliably to EPT.
    (Falling, Andreason, 1976) and (Fuss, Trowbridge 1986). The complete development of the Plexus of Raschkow does not occur until the final stages of root development (Fearnhead 1986 The histologic demonstration of nerve fibers in dentin).
  36. Where you test is critical in EPT and Cold tests.
    • (Bender, 1989). Incisal edge of anterior teeth
    • (Jacobson JJ, 1984). Occlusal-third of buccal surface of bicuspids for EPT
  37. Thermal test, how do they work?
    These tests are thought to work by hydrodynamic forces in the dentin initiating generator potentials in the nerve endings of displaced surface membranes. By this theory, fluid movement in the tubules (due to thermal stimulation) is responsible for activation of sensory receptor units in the pulp. (Brannstrom 1972).
  38. Most effective Cold Tests
    The most effective cold tests are those with CO2 (-78°C) and DDM (diflurochlormethane) (-50°C) (Fuss, Trowbridge 1986 Assessment of reliability of electrical and thermal pulp testing agents)
  39. Potential for extreme cold to cause crack in dentin or irreversibly damage the pulp
    Have been shown to be unfounded (Ingram, 1983) and (Rickoff, Trowbridge, 1988)
  40. Abnormal but positive responses are equally distributed among pulps of teeth in all diagnostic categories.
    (Seltzer & Bender, 1963). A positive response is an indication that the pulp is vital but does NOT indicate if the inflammation is irreversible. A negative response is highly indicative of necrosis.
  41. CO2
    has advantage over other sensitivity tests in that it can be used with metallic and porcelain restorations, ortho bands, metallic splints, temporary and permanent crowns. It is the MOST effective vitality test for immature teeth. (Fuss, Trowbridge 1986)
  42. Accuracy of Cold tests (Petersson,1999)
    • 90% accurate
    • Probability of negative test being necrotic pulp: 89% cold test, 88% EPT and 48% hot test
    • Probability of positive test being vital pulp: 90% cold test, 84% EPT and 83% hot test
  43. Percussion
    Not a true vitality test. It indicates periodontal ligament inflammation. A positive test indicates inflammation of the periradicular tissues. However a negative percussion test does not rule out the presence of inflammation. (Seltzer & Bender, 1963). A positive percussion test in a tooth that test vital to sensitivity tests is an indication of severe and probably irreversible inflammation in the pulp.
  44. Palpation
    This test is used to detect inflammation in the mucoperiosteum around the root of the tooth. It may be possible to detect tenderness, fluctuation, hardness or crepitus BEFORE extensive swelling is present. Negative results to palpation does not mean that inflammation is absent. (Seltzer & Bender, 1963).
  45. There is a poor correlation between clinical symptoms and pulpal histopathology.
    • •Tyldesley & Mumford, 1970 (Dental pain and the histologic condition of the pulp) Classic: Examined 142 teeth with pain. No correlation between histology and clinical symptoms.
    • •Mejere, Cvek 1993 Partial Pulpotomy in young permanent teeth with deep carious lesions – Vital pulp therapy (partial pulpotomy with CaOH dressing)was 93.5% successful @ 56 month
  46. Radiographic Exam Overview
  47. Can a PARL be seen with irreversible pulpitis?
    • Yes – Yamasaki – Rat study demonstrating PARL prior to pulp necrosis
    • Jordon, Suzuki & Skinner – PARL with IP; 11/24 healed with IDPC
  48. How much bone loss before a PARL is noted radiographically?
    • Bender – Avg 7% MBL & at least 12.5% CBL; lesion must penetrate endosteum
    • Lee & Messer – Lesions in cancellous bone detected if lamina dura is affected
  49. What radiographic features are important when evaluating PA pathology?
    Kaffe & Gratt – continuity & shape of lamina dura; width & shape of PDL
  50. How many films should be taken for diagnosis?
    Byrnholf – 73% accurate with 1 film; 87% accuracy with 3 films
  51. How accurate is our radiographic assessment?
    Goldman, Pearson & Darzenta - 6 examiners agreed 47%; 6-8mo later they agreed approx. 80% with their first interpretation
  52. What is the most accurate technique?
    Forsberg – paralleling is more accurate in length determination vs. bisecting angle
  53. What type of conventional film (speed) is the most diagnostic?
    Eleazer & Farman – NSD in WL measurements or image preference
  54. Compare conventional radiography to digital:
    • Evaluating for PARL
    • Mistak & Loushine – NSD between digital, transmitted digital & conventional radiography for PARL identification
    • Folk – NSD between shick (cmos) & trophy RVG ui (ccd)
    • Nair – conv. film displayed the highest % of PARL detection (vs. ccd & storage phos.)
  55. Comparing WL measurements
    • Lamus & Katz – NSD between shick & conv.
    • Goodell & McClanahan – Kodak > schick or conv. for size 10 & 15 files
    • Lozano – Conv. was more precise with any size file (digital ok with size 15 file)
  56. How much radiation reduction is there between digital and conventional radiography?
    • Soh – Used only 22% of radiation dose compared to conv. film
    • Ludlow, Platin & Mol – Insight (f speed) required 44% of exposure of Ultra (D speed)
  57. Is 3-D imaging better than conventional radiography?
    Low – improved detection of PA lesions and missed canals with Cone-beam Tomography
  58. Subjective / Objective Overview
  59. Can pts. determine which tooth hurts?
    Friend & Glenwright - No, only 37% accurate; usually tooth to either side; 3.4% referral to opposite jaw; 1.5% referral across midline
  60. Discuss cold testing?
    • Trowbridge & Franks – response sooner than temp change @ PDJ – supports Branstom
    • Walton / Miller – response quicker with endo ice; use with FCC
    • Jones – use large cotton pellet
  61. Who discussed heat testing?
    Cooley – hot water test
  62. Does temp testing harm the tooth?
    • Peters – CO2 does not harm the enamel
    • Rickoff & Trowbridge – heated GP or CO2 showed no pulpal injury
  63. Discuss EPT?
    • Nahri – stimulates A-beta and A-delta fibers; not C-fibers
    • Abdel Wahab & Kennedy – slow increase in current – 2uA/sec
    • Mumford – no relationship with value and pulp pathology
  64. Where do you place the probe tip?
    • Bender – incisal-edge of incisors
    • Jacobson – occlusal two-thirds of the buccal surfaces of max incisors and premolars
  65. Is EPT safe on pts. with pacemakers?
    Yes – Baumgartner
  66. Can you tell the histologic dx from clinical test?
    Seltzer & Bender – No, only correlation exists, but not extent of pathology
  67. How reliable are our pulp tests?
    • Petterson & Soderstrom –
    • probability the neg.=necrosis: cold – 89%; EPT – 88%; hot – 48%
    • probability the pos.=vital: cold – 90%; EPT – 84%; hot – 83%
    • Fulling & Andreasen – cold test are more reliable in kids
  68. Do any other pulp tests have potential?
    • Ingolfsson & Tronstad – Laser dolpler flowmetry is more accurate than EPT
    • Wilcox & Johnson – pulse oximetry
  69. What causes pain while flying / diving?
    Ferjentsik – Barodontalgia - Navy study found 86% with faulty restorations
  70. American Board of Endodontics Pulpal & Periapical Diagnostic Terminology:
  71. PULPAL:
    • Normal pulp – A clinical diagnostic category in which the pulp is symptom free and normally responsive to vitality testing.
    • Reversible pulpitis – A clinical diagnosis based upon subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal.
    • Irreversible pulpitis – A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing.
    • Additional descriptions:
    • Symptomatic – Lingering thermal pain, spontaneous pain, referred pain
    • Asymptomatic – No clinical symptoms but inflammation produced by caries,
    • caries excavation, trauma, etc.
    • Pulp necrosis – A clinical diagnostic category indicating death of the dental pulp. The pulp is non-responsive to vitality testing.

    • Previously Treated – A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials, other that intracanal medicaments.
    • Previously Initiated Therapy – A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (e.g. pulpotomy, pulpectomy).
  72. APICAL (PERIAPICAL):
    • Normal apical tissues – Teeth with normal periradicular tissues that will not be abnormally sensitive to percussion or palpation testing. The lamina dura surrounding the root is intact and the periodontal ligament space is uniform.
    • Symptomatic apical periodontitis – Inflammation, usually of the apical periodontium, producing clinical symptoms including painful response to biting and percussion. It may or may not be associated with an apical radiolucent area.
    • Asymptomatic apical periodontitis – Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area and does not produce clinical symptoms.
    • Acute apical abscess – An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation and swelling of associated tissues.
    • Chronic apical abscess – An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort and the intermittent discharge of pus through an associated sinus tract.
  73. Support your diagnosis of irreversible pulpitis in this asymptomatic cariously exposed tooth.
    • Reeves R, Stanley MR. The relationship of bacterial penetration and pulpal pathosis in carious teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1966.
    • Studied 46 carious teeth. If bacteria were 1.1-2.4mm from the pulp, little pulpal pathosis was observed. If bacteria were within 0.5mm or invaded reparative dentin, irreversible pulpal damage was observed.
  74. Discuss cold testing. How cold is it? Is it safe for the pulp?
    • Trowbridge and Franks (1980) in a classic in vivo/in vitro study, determined that the sensory response to thermal stimulation occurs before there is a temperature change in the region of the pulpodentinal junciton (PDJ); therefore the response is due to the Hydrodynamic Theory as put forth by Branstrom
    • • CO2, -108F
    • • Endo Ice, -15F Dichlorodifluoromethane
  75. Does Cold/Hot test injure the tooth?
    • CO2 does not harm the enamel; (Peters 1986)
    • Rickoff B, Trowbridge H, Baker J, Fuss Z, Bender IB. Effects of thermal vitality tests on human dental pulp. J Endod 1988.
    • • Histo study of teeth tested with heated GP and CO2 snow showed no pulp injury 1h-2w following testing
  76. What about heat testing. When would you use that?
    • Cooley RL, White JH, Barkmeier WW. Thermal pulp testing. Gen Dent 1978.
    • Discussed heat vitality testing using hot water (<140F).
  77. This pt’s tooth hurts when flying. What’s up with that?
    • Holowatyj RE. Barodontalgia among flyers: a review of seven cases. J Can Dent Assoc 1996.
    • Causal process of barodontalgia is not well understood, it may be related to pulpal hyperemia, or to gases that are trapped in the teeth following incomplete root canal treatment.
  78. Can you make a histologic diagnosis from clinical signs and symptoms?
    • Seltzer S, Bender I, Zionitz M. The dynamics of pulp inflammation: correlations between diagnostic data and actual histologic findings in the pulp. Part I. Oral Surg 1963.
    • • Can't tell histologic pulp status from diagnostic tests. In vivo study found that correlations exist between subjective symptoms, objective signs and radiographic findings as to the histologic status of the pulp, but NOT the extent of the pathology.
    • Reynolds (1966); no correlation between symptoms and histology (55 of 56 teeth were asymptomatic and many had histologic inflammation)
  79. Which method of determining pulp responsiveness correlates best with pulpal histology?
    • Laser Doppler Flowmetry (LDF) has great potential; Ramsay (1991)
    • • Ingolfsson & Tronstad (1994 EDT): Laser doppler more accurate than EPT for necrotic pulps (91% vs 64%)
    • Pulse oximetry also has excellent potential; Noblett and Wilcox (1996)
  80. Can patients accurately determine which tooth hurts?
    • No, not unless periapical involvement
    • Friend LA, Glenwright HD. An experimental investigation into the localization of pain from the dental pulp. Oral Surg Oral Med Oral Pathol 1968.
    • Pulpal pain it is difficult to localize. It is usually possible to localize pain to within one tooth on either side of the tooth concerned. Difficulty of localization increases toward the back of the mouth.
    • 3.4% of stimuli were incorrectly identified in the opposite jaw.
    • 1.5% were incorrectly identified across the midline.
    • Overall, accuracy for all teeth was 37.2%.
  81. Discuss EPT.
    • A beta and A delta fibers respond to the EPT test. Not C fibers Narhi (1979)
    • Seltzer & Bender (1963 ): Negative EPT = complete or partial necrosis 97.7% of the time
    • Fuoad (1991)- EPT safe with pacemakers
    • Mumford (1961) showed no direct relation-ship between threshold values (on the display screen) and pulp pathology
  82. Where should EPT probe be placed?
    • Bender IB, Landau MA, Fonsecca S, Trowbridge HO. The optimum placement-site of the electrode in electric pulp testing of the 12 anterior teeth. J Am Dent Assoc 1989.
    • Apply the electric pulp tester to the incisal-edge in anterior teeth.
  83. How fast should current be increase in EPT?
    • Abdel Wahab MH, Kennedy JG. The effect of rate of increase of electrical current on the sensation thresholds of teeth. J Dent Res 1987.
    • Slowly increasing current gave more accurate and reproducible results than did rapidly increasing current. Use the same rate of current increase.

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