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  is the correct determination, discriminitive
estimation and logical apraisal of conditions found
during examination as evidenced by distinctive
signs,marks and symptoms.
? |t is also defined as an art of distinguishing one disease
from the another.
? Vs a correct treatment begins with a correct
diagnosis,So diagnostic procedures should follow
consistent logical order which includes comprehensive
medical and dental history,radiographic
examination,extraoral and intraoral clinical
examination including histopathological examination
to arrive at final diagnosis.
? Process begins with the initial call requesting
appointment for some specific reason,usually a
complaint of pain.
? Subjective symptom is supplied by the written history
or questionnaire that each patient completes and
signs.
? Further information is obtained by the clinician, who
reviews the questionnaire and ask specific questions
regarding the patientǯs chief complaint ,past medical
history ,past dental history, present medical and dental
status.
? Clinician should consult to the patientǯs physician
whenever patient appears to be medically
compromised or when the gained information is
inadequate or unclear.
? ’edical history is important because
medical history affects the course of
treatment,especially concerning the use of anaesthetics
,antibiotics and analgesics.
? Occasionally a patients medical status bears a direct
relation to the clinical diagnosis.For ex- Difffuse pain in
the mandibular left molars may be a referred pain
caused by angina pectoris, or Bizarre symptoms may be
the result of psychogenic and neurologic disorders.
  
 
? Case history is defined as data concerning an individual and
his or her family and environment,including the individual
medical history that may be useful in analyzing and
diagnosing his or her case or for instructional purposes.
? Vs many disease has similar symptoms the clinician must be
astute in determining the correct diagnosis.
? Differential diagnosis is the most common procedure . This
techique distinqishes one disease from several other similar
disorders by identifying their differences.
? On the other hand diagnosis by exclusion eliminates all
possible disease under consideration until one remaining
disease correctly explains patients symptoms.
Ý 
? Symptoms are the units of information sought in
clinical diagnosis.
? Symptoms are defined as phenomena or signs of
departure from normal and indicative of
illness.Symptoms can be classified as follows:
? Subjective symptoms: Those experienced and reported
to the clinician by the patient.
? Objective symptoms:those ascertained by the clinician
through various tests.
Ý   
? Completed medical form concerning the patient,s past
dental history consist of subjective symptoms.
? Patient,s reason for seeing the dentist is subjective
symptoms. Generally a chief complaint relates to pain,
swelling and esthetics.
? PV| :
most common problem that leads to dental treatment
Questions about pain should be asked such as: kind of
pain, its location ,its duration ,what causes it,what allevates
it whether its is referred to other side or not..
Generally pulpal pain is described in two ways by the
patient.
1. Sharp,Piercing and lancinating type
? 2.Dull, boring ,gnawing and excruciating type
? Vfter this the ability to localize the pain is also important .
Whether the pain is localized or diffused.
? Pain is localized when the patient point to a specific
tooth or site with assurance and speed when asked to
do.
? Pain is diffused, when the patient describe an area of
discomfort rather than a specific site.
? When the patient is asked to to point to the most
painful spot,patient,s finger move along the dental
arch or between the maxilla and mandible.
? Diffuseness is diagnostic because the inability to
localize the pain frequently relates to dental pain that
is dull,boring grawning,from a tooth that respond
abnormally to heat more than to cold and with
symptoms that can be referred to other sites.
? Duration: duration of pain is also diagnostic,as pulpal
pain lasts only as long as an irritant is present.Vt other
times it may last minutes to hours.
? Pain may either be intermittent or constant.
? Clinical experience has shown that a tooth fleeting
pulpal pain which disappear on removal of irritant has
an excellent chance of recovery without the need of
endodontic treatment.
? Vcute reversible pulpitis is characterized by pain of
short duration,caused by a specific irritant which
disappear as soon as the irritant is removed. Pain is
usually localized and is more responsive to cold than
heat.
? |f the pain persist persists or if it occurs without any
apparent cause ,the pulpitis will usually be
irrerversible and the patient will require endodontic
therapy.
? Spontaneous pain and pain of long duration indicated
irreversible pulpitis.
? Vbnormal dental pain caused by heat usually requires
endodontic treatment.
? Pain that occurs on changing the position of head
awakens the patient from sleep or occurs during
mastication of food in a cariously exposed tooth
usually indicate endodontic treatment.
©  Ý 
Objective symptoms are performed by the tests and
observations performed by the clinician . These test
includes:
1) Visual and Tactile inspection
2) Percussion
3) Palpation
4) ’obility and depressibility
5) Bite test
6) Radiograph
7) Electric pulp Test
8) Thermal Tests( hot and cold)
9) Vnaesthetic test
10) Test Cavity
 


 |  

? Visual and tactile examination of hard and

soft tissues relies on checking : Color
Contour
Consistency
|n soft tissues such a gingiva deviation from the
healthy pink color is recognized when inflammation is
present,Change in contour occurs during
swelling,Change in consistency from
normal,healthy,firm tissue to soft,fluctuant and
spongy tissue indicate a pathologic condition.
? Similarly teeth should be visually examined using the
three Cs. such as Color
Contour
Consistency
COLOR: V normal appearing crown has a leaf-like
translucency and sparkle that is missing in pulpless teeth.
Teeth that are discolored, opaque and less leaf-like
appearance should be carefully evaluated because the pulp
may already be inflamed ,degenerated and necrotic.
ot all discolored teeth need endodontic treatment
,sometimes dicolration may be caused by old amalgam
restoration,root canal filling materials or medicaments or
systemic medications.
? ’any discoloration however are the result of disease
commonly associated with necrotic, gangrenous pulps,
internal or external resorption and carious exposure.
? CO TOURS: contours should be well examined
because fractures ,wear facets,and restoration change
the crown,s contour.
? CO S|STE CY: consistency relates to the presence of
caries ,internal and external resorbtion.
     


  



? One use eyes, finges ,explorer and periodontal probe.
? Patients teeth and periodontium should be examined in
good light under dry conditions. For example: V sinus tract
might escape detection if it is covered by saliva OR
inerproximal cavity may escape if it is filled with food.
? Loss of translucency,slight color changes and cracks may
not be apparent in poor light. |nfact, Transluminator may
aid in detecting enamel cracks or crown fractures.
? V|SUVL EXV’| VT|O : should include the soft tissue
adjacent to the involved tooth,for detection of swelling.
? Periodontal probe should be routinely used to
determine the periodontal status of suspected tooth
and adjacent tooth. Sinus tract opening into the
gingival crevice or deep in infrabony pockets may go
undetected because of failure to use periodaontal
probe.
? Periodontal pocket probing depths must be measured
and recorded.V significant pocket in absence of
periodontal disease may indicate root fracture.
x |
Ý ÝÝ|||©
? For furcation defects
? Grade 1: incipient lesion when the pocket is suprabony
involving soft tissue and there is slight bone loss.
? Grade 2: Bone is destroyed on one or more aspects of
the furcation but probe can only penetrate partially
into the furcation.
? Grade 3: |ntraradicular bone is comletely absent but
the tissue covers the furcation.
? Grade 4: through and through furcation defect.
  
? Percussion evaluate the status of the periodontium
surrounding a tooth.
? Tooth is struck with a quick,moderate blow ,initially
with low intensity and than with increasing intensity
by using the handle of the instrument,to determine
whether the tooth is tender.
? V sensitive response to differing from that of adjacent
teeth usually indicate presence of Vcute apical
perodontitis.
? One must not percuss a sensitive tooth beyond the
patients tolerance.
? Percussion is used in conjunction with other
periodontal tests, namely palpation, mobility,and
depressibilty. These tests help to corroborate the
presence of periodontitis.


 
? Simple test done with finger tip,using light pressure to examine
tissue consistency and pulp response.
? Vlthough it is a simple test but its value lies inlocating the
swelling over an involved tooth and determine :
? (V) Whether the tissue is fluctuant and enlarged sufficiently
for incision and drainage.
? (B) Presence,intensity and location of pain
? (C) Presence and location of Vdenopathy
? (D) Presence of bone Crepitus
when the infection is confined to the pulp and has not progressed
into the periodontium,palpation is not diagnostic.
So, palpation is test for integrity of the attachment apparatus i.e
periodontal ligament and bone not diagnostic when disease is
confined with in the pulp cavity of tooth.
   m    
? ’obility test is used to evaluate the integrity of the
attachment apparatus surrounding the tooth.
? Test consist of moving a tooth laterally in its socket by
using the fingers or preferably the handles of two
instruments.
? Objective is to determine whether the tooth is firmly
or loosely attached to its alvelolus.
? Vmount of movement is indicative of the condition of
the perodontium,greater the movement ,poorer the
periodontium status.
 Depressibility test consist of moving a tooth vertically in its
socket.
Test may be done with fingers or with instrument.
When depressibility exists the chance for retaining the tooth
ranges from poor to hopeless.
TOOTH ’OB|L|TY:
Tooth mobility can be classified as :
First degree: a noticiceable movement of tooth in its socket.
Second degree: movement of tooth with in a range of 1mm.
Third degree: movement greater than 1mm or when tooth can
be depressed.
? Endodontic treatment should not be carried out on
teeth with third degree mobility unless mobility is
reduced when pressure in the periodontium has
relieved
× 
? Bite test is useful in identifying a
cracked tooth or fractured cusp.
? Vlso help in diagnosing cases wherein
the pulpal pathosis has extended in the periradicular region
causing apical periodontitis.
? Tooth slooth and Frac Finder is commercially available
device for the bite test.
? Clinician should note whether the discomfort or pain
occurs during the act of biting or during the release of bite
force.
Pain on Biting Ȃ Vpical periodontitis
Pain on release of biting force Ȃ cracked tooth
m|©x
? One of the most important tool in making a diagnosis.
? |t permits visual examination of oral structures that
would otherwise be unseen by the naked eyes.
? Practice of dentistry would be impossible without
radographs.
? To use radiograph properly clinician must have the
knowledge and skills to interpret them correctly.
? clinician must know about underlying normal
anatomical structures ,anomalous anatomy and the
changes that occur due to aging , trauma ,disease and
healing.

   
? ’ore accurate method used to determine the pulp
vitality.
? Electric pulp tester, when testing for pulp vitality uses
nerve stimulation instead.
? Objective is to stimulate a pulpal response by
subjecting the tooth to an increasing degree of electric
current.
? Positive response indicates vitality and help in
detemining the normality and abnormality of pulp.
? o response to electrical stimulus can be indication
of pulp necrosis.
   
1.Describe the test to the patient in a way that will reduce
anxiety and will eliminate a biased response.
2.|solate the area of teeth to be tested with cotton rolls and
saliva ejector and air dry all the teeth.
3.Check the electric pulp tester for function and
determine that current passing through the
electrode.
4.Vpply the electolyte( toothpaste) on the tooth electrode
and place against the dried enamel of crownǯs
occlusobuccal and incisolabial surface.
Vvoid contacting any restorations in the tooth or adjacent
gingival tissue with the electrolyte because it gives false
response/ misleading response.
5. Retract the patientǯs cheek away from the tooth
electode and the electical circuit is completed by
either asking the patient to touch the metal handle or
using a lip clip.
6. Turn the rheostat slowly to introduce minimal current
into the tooth and increases the current slowly.

Vsk the patient to indicate when sensation occurs by

using such words as DzTinglingdz and DzWarmthdz. Record
the result according to the numeric scale on the pulp
tester.
7. Repeat the foregoing for each tooth to be tested.
? |ncisal third of the anterior and mid third of the
posterior teeth are the most ideal region for placing
the tester because of highest nerve density.
 
 
? This test involves application of cold and heat to
determine the sensitivity to thermal changes.
? Vlthough both are tests of sensitivity , they are
dissimilar and are conducted for different diagnostic
reasons.
? V response to cold indicates a vital pulp,regardless of
whether that pulp is normal or abnormal.
? V heat test is not a test of pulp vitality.
? Vn abnormal response to heat usually indicates the
presence of a pulpal or periapical disorder requiring
endodontic treatment.

 
? Heat test is performed using different techniques that
deliever different degree of teperature.
? Vrea to be tested is isolated and dried ,warm air is directed
to the exposed surface of tooth.
? |f high temperature is needed hot water, hot burnisher ,
hot gutta percha and hot compound are used.
? When using a solid substance such as guttta percha heat is
applied to the occlusobuccal third of the exposed crown. |f
no response occurs, the host substance can be moved to the
central portion of the crown or closer to the tooth cervical
margin.
? When a response occurs heat should be removed
immediately .
? For the application of hot water a different technique is
used.
? Tooth to be tested is isolated under a rubber dam.
? Tooth is than immeresed in Dz Coffee hot Dz water
delievered from a syringe. Vnd than the patient
reaction is noted.
 
Cold test can be performed in several different ways.
? V stream of cold air can be directed against the crown of
previously dried tooth and also at the gingival margin. |f no
reaction occurs, tooth can be isolated under a rubber dam
and sprayed with ethyl chloride which evaporates more
rapidly. That it absorbs heat and there by cools the tooth.
? ’ore common method is apply a cotton pellet saturated
with ethyl chloride spray to the tooth being tested.
? Carbon dioxide spray (dry ice) can also be used for the
application of cold to teeth.
? Use of dry ice is described by : Ehrmann
? Temperature of Dry |ce is -78 degree

   
? Restricted to patients who are in pain at the time of
test when the ususl tests have failed to identify the
tooth.
? Objective is to anaesthesize one tooth at a time untill
pain disappears and is localized to a specific tooth.
? Technique: using infiltration or intraligament
injection,inject the most posterior tooth in the area
suspected of being the cause of pain.
if pain persist when the tooth has been fully
anesthesized , anesthesize the next tooth mesial to it
and continue to do so untill pain disappears.
? |f pain can not be identified from maxillary or
mandibular origin an inferior alveolar block is given.
Cessation of pain naturally indicate involvement of a
mandibular tooth.
? localization to a specific tooth is done by intraligament
injection.

 
? Done for determination of pulp vitality.
? Test cavity is made by drilling through the enamel-dentin
juction of unanesthesized tooth.drilling should be done at
slow speed and without a water coolant.
? Sensitivity or pain felt by the patient is indication of pulp
vitality; no endodontic treatment is indicated.
? Sedative cement is then placed in the cavity and the search
for the source of pain continues.
? |f no pain is felt, cavity preparation may be continued
untill the pulp chamber is reached.
? |f the pulp is comletely necrotic ,endodontic treatment can
be continued painlessly in many cases without anaesthesia.
   
  

? ’ost common methods to assess pulp vitality are
based on sensitivity assessment of the neutral tissues
of pulp. These include thermal and electrical pulp
tests.
? True vitality statues can be ascertained only when we
are able to assess the vascular or blood supply to the
tooth.
? Two recent technologies are:
1.Pulse oximetry
2.Laser doopler Flowmetry