1. Diagnosis of Pulpal pathology
Abdullah Karamat

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

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

4. History
• Presenting complaint :
Patients should be
questioned sympathetically and asked to
describe their complaint in their own words;
this should then be documented.

5. • History of presenting complaint :
The history of
presenting complaint is divided into five basic
directions of questioning :
1- Localization: “Can you point to the
offending tooth?”
2- Commencement: “When did the symptoms
first occur?”

6. 3- Intensity: “How intense is the pain?”
4- Provocation and Relief of Pain: “What
produces or reduces the symptoms?”
5- Duration: “Do the symptoms subside
shortly, or do they linger after they are
provoked?”

7. • Dental history :
- Past dental clinic attendance
- Possible contributing factors towards
patient’s present condition.
- Proper documentation

8. • Medical history :

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

10. • Extra oral examination :
Examine for :
1- localized swellings
2- facial asymmetry
3- change in color
4- lymph node examination

11. 5- trauma
6- sinus tract
7- cancer screen ( soft tissue examination
, lumps and white spots )
8- temporomandibular joint

14. Intra oral examination :
Examine for :
1- intra oral swellings
2- soft tissue examination
3- intra oral sinus
4- hard tissues

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

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

21. Light finger pressure is applied in a rolling
motion to palpate the soft tissues

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

23. Tooth percussion performed using a forefinger

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

25. The periodontal probe must be walked around
the tooth to ensure that any isolated narrow periodontal
defects are not missed.

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

27. Mobility testing of a tooth, using the back ends of two
mirror handles.

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

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

30. False positve :
If cold contacts gingiva or is
transferred to adjacent teeth with vital pulps.
False-negative :
Is often obtained when cold is
applied to teeth with calcified canals,

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

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

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

34. d – Laser Doppler flowmetry :
A diode is used to project an infrared light
beam through the crown and pulp chamber of
a tooth. The infrared light beam is scattered as
it passes through the pulp tissue. The Doppler
principle states that the light beam will be
frequency-shifted by moving red blood cells
but will remain unshifted as it passes through
static tissue

35. e- Pulse oximeter :
It is designed to measure the oxygen
concentration in the blood and the pulse
rate.

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

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

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

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

42. Liquid Crystal Testing :
Cholesteric liquid crystals have
been used by investigators to show the
difference in tooth temperature between
teeth with vital (hotter) pulps and necrotic
(cooler) pulps.

43. Hughes Probeye camera :
Is capable of detecting
temperature changes as small as 0.1°C, has
also been used to measure pulp vitality
experimentally

44. Selecting the Appropriate Pulp Test :
The selection depends on the situation. When
cold (or hot) food or drink initiates a painful
response, a cold (or hot) test is conducted in
place of other vitality tests. Replication of the
same symptoms in a tooth often indicates the
offender. Overall, electrical stimulation is similar
to cold (refrigerant) in identifying pulp necrosis;
heat is the least reliable stimulus.

45. Differential diagnosis :
• Pulpal conditions
a- Normal pulp
A tooth with a normal pulp will be symptom-
free. The results of clinical examination will be
unremarkable, and the tooth will respond
normally to sensitivity testing

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

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

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

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

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

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

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

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

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

55. References :
1- Harty
2- Torabinejad
3- Ingle
4- Weine
5- Jayshree and Hedge