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Few notes before beginning our lecture as the doctor said : about intraoral examination you have to: * check the buccal mucosa.. *check the orifices of parotid glands *check the foliate papillae and any granules on the tongue *check everything that we learnt in previous lectures to differentiate normal anatomy from abnormal.
Diagnostic tests
There is no treatment without taking history and chief complaint . There are tests that we do routinely in dental clinic and tests that we do in the laboratory In the clinic we do routinely dental test for diagnosis any non vital pulp
In general we do thermal test (cold is preferable than heat) if doesn`t work we do alternative test which is electrical test and if it doesn`t work due to inflammation we do another method what`s we call latitude test (not sure about the name) this test we cutting an access cavity without anesthesia and if the pt feel pain when we reaching the dentine we conclude his tooth is vital .. Before we doing vitality test we have to take history chief complaint radiographs after that we do vitality test .. Vitality tests Provide an adjunct to determining the state of pulp Sometimes we need to do more than one vitality test to reach the exact diagnosis.. Results must be interpreted with caution
You should know that you may face False positive and false negative results and this common in vitality test be careful ex. Syphilis is associated with stigma and the result is positive you have to be familiar with each test and rule out the result That`s why we doing more than one test.
Surrounding and contralateral teeth should also be tested to compare between the result and knowing the non vital teeth.. Test should begin on a normal tooth because there are pts tell you all their teeth are painful when you touch everywhere is tender including vital teeth that`s why you should begin on a normal tooth Stimuli should be applied to normal enamel of the crown of the tooth not to restorative material or soft tissue to avoid either false negative or false positive -2-
Better results if more than one test is used ( heat and cold, or cold and electrical tests to compare the results as we said
*-* Prior to operative procedures before doing access cavity do vitality test to know that you should to do amalgam restoration or RCT make sure that you have a time to do operative procedures don`t prepare an access cavity if you don`t have enough time to finish your work .. *-* Diagnosis of pain you have to differentiate between the pain of the teeth and the pain from nausea
*-* Investigation of radiolucent areas especially in periapical lesions are from pulpal origin not a cyst or periapical abscess or normal anatomy like mental foramen in between premolars area *-* Post-trauma assessment like fracture in the mandible or dislodged teeth we repositioning the tooth and we do vitality test to check if it`s vital or not *-* Assessment of anesthesia .. before giving LA we want to know if the tooth is painful especially in children *-* Assessment of teeth which have been pulp capped or required deep restoration to know if the tooth still vital
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1)
Cold Test
Involves using a refrigerant, such as endo-ice(we use in the clinic) ( ) , ethyl chloride spray .. some dentist use the ice from the refrigerator or fill the carpool of LA water and putting it in the refrigerator and using it as ice and do this test .. The doctor doesn`t advice this method (filling the carpool water to avoid cross infection) The pts who have caries know when drinking cold water the teeth start to be painful and this is the principle of this test We put the ethyl chloride spray on The middle third of the clinical crown for posterior teeth and the border between the coronal and middle thirds of the clinical crown for anterior teeth (always choose the sound enamel )
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1.endo ice
2. cotton pellet in tweezers 3. Apply the icy pellet to the facial surface of the tooth
If the patient rise his hand and his tooth is painful and the pain sharp and linger it`s a symptom of irreversible pulpitis. If the pain sharp and doesn`t linger it`s a symptom of reversible pulpitis.
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If there is no pain (no response to cold test ) we have to think about pulpal necrosis or we have to do another test which is EPT in case of non responsive to cold test In case of sclerosis of the canals..
2) Heat Test Apply to the vaseline-coated surface of the test tooth to adhere to the tooth Use a ball of softened gutta percha on the tip of a plastic instrument (guttapercha softens at 65 C) This test is difficult because we have to heat the gutta percha at 65 C and we dont know the exactly temperature while heating it Place the gutta percha onto the tooth the same way you would the ice Wait approximately 5 seconds (in the book written 15 sec but the doctor said it`s too long and 5sec is enough) Compare the results from other tested teeth
The use of hot water, administered through an irrigating syringe under rubber
dam isolation (can we use this method in cold water test to isolate the non vital tooth when we suspicious )
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Disadvantages:
*-* May be difficult to use on posterior teeth because of limited access *-* Excessive heating may result in pulp damage *-* May result in a lingering pain, therefore heat tests should be applied for no more than 5 seconds *-* Inadequate heating of the gutta-percha stick could result in the stimulus being too weak to elicit a response from the pulp
Place the tip on the middle of the facial surfaces of the tooth Do not place the probe on a restorative material (metal, composite, ceramic) or touch gingival tissues because these materials give us false positive !!!! (exaggerated response to the test)
Have the patient touch the handle of the device with a finger ( in order to ground the unit to complete the electric circuit) Start by pressing and holding the start button Gradually increase the voltage until a response is elicited (you can set the voltage either medium or high. The doctor said keep it medium) - When the patient indicates a response, release the start button The reading will be fixed on the display for some time after the button is released the reading is stays on the screen up to 5 min !! ex. 40 voltage is the positive response A response to the maximum reading (e.g. reading of 64 is usually indicative that the pulp of the tooth being tested is nonvital) If we reach the max. reading we conclude that pulp is not vital!!
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*-* Between 40-80,with abovementioned reaction, partially vital pulp (one or more canals are vital in multi rooted teeth )
There are many of devices you should read all the manufacture instruction of each device and the max. voltage of each one .. there are many types of devices some of them here and you can see the others in GOOGLE .
A hook on the patients lip completes the circuit Electrical conducting gel is present between the electrode and the tooth
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The most desirable area of assessment is at the incisal edge of incisor teeth, and the mid-third region of posterior teeth (on the tip of the mesiobuccal cusp on molars ) because these areas close to the pulp horn
Recently traumatized teeth Sclerosed canals Recent orthodontic activation Patients with psychotic disorders
Chronic pulpitis; if gradual reaction to heat, but not to cold or electrical stimulation leads to an exaggerated response
False Positive
As we said in the electric pulp testing give us positive result but the tooth is not vital !! this what we call false positive We face this condition in : *-* The test unhealthy tooth responds normally
False positive the tooth is
*-* Occur in anxious or young patients *-* Contact with metal restorations (electric test) *-* Inadequately dried teeth ( electric test) *-* Multi rooted teeth with one vital root canal pulp *-* In a root canal filled with pus or gas *-* In a patient with low pain threshold
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False Negative
Teeth with restorations ( heat and cold test) Teeth with secondary dentine Nerve supply to the pulp is damaged (e.g. trauma) In a patient with a high pain threshold Faulty technique or equipment .. (if you dont use gel in electric pulp test )
Inconclusive Result
All teeth give similar responses: conflictive results If the results of two tests are inconclusive add a third test Consider cutting a diagnostic access cavity without local anesthesia when we reach the DEJ the pt feels pain and we know that tooth is vital
We use this test When dental symptoms are poorly localized or referred, an accurate diagnosis is extremely difficult Using either inltration or an intraligamentary injection, the most posterior tooth in the area suspected of causing the pain is anaesthetized If pain persists, the tooth immediately mesial to it is then anaesthetized, and so on, until the pain disappears
Laser Doppler owmetry: a non-invasive , painless technique with direct and objective registrations, but has limitations : environmental and technique-related factors. Nonpulpal signals, principally from periodontal blood flow, may contaminate the signal Pulse oximetry: measure oxygen saturation levels May be the tooth is vital but there is no nerve stimulation in the pulp in such case this tooth is beneficial
A LDF probe applied to a sectioned tooth showing the passage of light via the enamel prisms and dentinal tubules to the pulp
Note : this test not required for us but who wants to use this test in his clinic and get information that test is exist
THE END
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