2. Diagnostic Tests Flashcards by J L

• When a tooth is hurting what is happening in the pulp?
◦ ____
◦ Disease process going on in the tooth for the patient to be in pain
• Where will there be more pain? Acute or chronic?
◦ ____
◦ Any acute inflammation in the pulp will cause pain

• Summary
◦ Inflammation in the pulp
◦ Inflammation from bacteria or products
◦ Which has caused inflammatory mediators
◦ The nerves that were earlier silent because of the inflammation are easily
____, spent excitable and that is why the pt is in pain

• Hyperalgesia: something that hurt before hurts ____ now because of inflammation
◦ ____ test is an example in the mouth
‣ WNL pain
‣ Inflammation: more painful in presence of inflammation

• Allodynia: something that is never ____ now is painful with inflammation
◦ Ex in the mouth: ____
◦ If the period ligament is inflamed the patient feels pain

inflammation
acute

excitable
more
cold

painful
percussion

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Possible Origins of Endodontic Pain

Pain process occurs mainly while tissue damage is ____ on, not ____ tissue injury

going

after

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Nociceptive Mechanism

A-delta fibers: ____
C-fibers: ____
C-fibers are more resistant to compromised ____: pain associated with a ____ pulp -> ____ stimulation

myelinated
unmyelinated and thinner
blood flow
necrotic
C-fiber

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Nociceptive Mechanism

• A delta are on the \_\_\_\_
◦ Pulp dentin junction
◦ Wrap around the \_\_\_\_ processes 
◦ Myelinated
‣ When you activate it sends info to the brain very quickly because it jumps node to node 
◦ \_\_\_\_ in size
◦ \_\_\_\_ pain

• C fibers are in the ____ proper
◦ Within the middle portion of the pulp
◦ Generally wrapped around ____
◦ ____ in size
◦ Non-myelinated
◦ To excite them it takes more inflammation and stimulus
‣ Have to get in the middle of the pulp to stimulate
◦ Because unmyelinated they send info to the brain much slower
◦ Pain comes on after stimulus ____
◦ ____ throbbing pulsing pain
‣ Pulsing in nature because it wraps around the bv
‣ So when the bv goes through ____ c-fibers are stimulated

periphery
odontoblastic
larger
sharp

pulp
blood vessels
thinner
delay
dull
systolic and diastolic

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Nociceptive Mechanism

• C fibers are more ____ to compromised blood flow
◦ Even when the pulp is necrotic, tissue is dying, some of the last things to die are the ____
◦ When a tooth is necrotic if you take up a bur and access without anesthesia you still provoke pain from
the remnant c fibers
‣ The resistant c fibers that do not die easily
◦ Hurts even though dx test says the tooth is ____

resistant
c fibers
necrotic

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Sharp Pain

A-delta fibers

Must be ____
____, momentary pain

pulpodentinal complex is ____
____ tissue injury

provoked
quick
intact
acute

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Dull Pain

C-fibers

Poorly ____
•Boring, throbbing
•Occurs as a ____ pain
•____ to anywhere in the ipsilateral face and jaws

” ____ injury
“ ____ mediators, vascular changes tissue pressure

____ pain happens because of the c fibers
When transmit to the brain cannot figure out where the pain is coming from

localized
secondary
radiate

tissue
inflammatory
referred

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Throbbing Pain

Inflamed pulp
Increase in ____ blood pressure activates pulpal neurons

systolic

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Spontaneous Pain

“Only significant correlation between clinical signs and pulpal pathology was with a history of ____ pain”

• 500 teeth on 500 pts
◦ Asked the pts what they were experiencing
◦ Did all the clinical tests on these patients
‣ Recorded the results ◦ Extracted the teeth
‣ They were meant for extraction anyways
‣ Made histology slides of the teeth
◦ Conclusion:
‣ What you see in histology in tooth rarely ____ to the pts experience and what the tests will show
‣ Why endo is challenging
• Histology does not always coordinate to ____ and what the pt is experiencing

• Why?
◦ perception of pain is very ____ to the person ◦ People do not perceive pain equally
‣ Pathogenesis is the same but ____ is individual
◦ Some its will never have pain
‣ Pulpitis –> necrosis with no pain

• Important conclusion from the study:
◦ If the patient comes to you with hx of spontaneous pain is indicative of severe ____ on one of the teeth / indicative of ____ is needed
◦ Our job is to figure out what tooth needs end
◦ Put the gathered information together to come up with a conclusion
◦ Only sign with conclusion is hx of sport pain

spontaneous
correlates
dx test
specific
perception
inflammation
root canal

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Heterotopic pain
When the source and site of the pain are different:
•____-referred Pain
•Referred Pain

Natkin et al. 1975:
18% of all the cardiac pain are localized sorely to the ____.

• Source of the pain is somewhere else and feeling it somewhere else
• Ex: heart attack see pain in their tooth
◦ ____ felt in the lower mandibular teeth

cardiac
teeth
angina

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Referred Pain
• Intense ____
• Inflammation confined within the ____
• Previous Hx of mild-moderate pain

> > > C-fibers&raquo_space;>

____, boring, continuous pain
____ teeth
____, one tooth only

stimulus
pulp

intense
posterior
unilateral

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Referred Pain

• One thing with no referral
• Front teeth do not cause referred teeth in the ____ teeth
• Does not cross the ____
• These are noted pains
• A tooth that is already instrumented, with a removed ____ (mid or complete pain) will not cause c-fiber pain
◦ Can rule that out right away
◦ Still throbbing and aching after root canal, different ____

• ____ does not cause c fiber pain
◦ The pulp is gone
◦ Draining, no buildup
◦ Chronic inflammation stage no accuse event here to cause pain

• ____ disease does not cause throbbing pulsing pain
◦ Causes ____ pain, deep seeded ache
◦ Question to ask: does it pulse or have a throb
‣ No = could be ____
‣ Yes = characteristic of ____ pain

back
midline
pulp
tooth

sinus tract
perio
dull
perio
pulp

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Chief Complaint
“Patient’s own ____ “____
“____

• Might be decay or perio disease but if they come to you for CC of pain that needs to be addressed first

words
priority
objectivity

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Quality of Pain

Sharp, stabbing -> ____ cause

Histologically, trend towards an increased pain in chronic partial pulpitis with necrosis & total pulpitis

odontogenic

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Affecting factors

Lying down or bending over exacerbate pain -> ____?
•Pain ____ after going to bed at night
• ____ them up after they have fallen asleep

Gravity
“Arterial pressure to head raised

Disturbance of sleep -> Inflamed pulp

• What increases the pain?
• Pulpal pain making people wake up
• C fibers are wrapped around blood vessels
• Pt is feeling ____ because the pain is pulsing
• When you lay down on a pillow the bloop pressure goes ____ transiently
◦ When it goes up the c fibers fire even quicker
• Pts who cannot ____ or need lots of ____ is characteristic of the pulpal pain
◦ Or sleep up
• Bending head down and eliciting pain
◦ Dx test you can ask them to put head between their legs
◦ If this illicit pain this could be ____ pain
• Lying down pain happens in a few minutes
• An ____ increase in pain with the head down is usually a sign of sinus pain
◦ Fluid in the sinus moves and that causes the pain ◦ ddx

sinus
shortly
wakes

throbbing
up
sleep
pillow
sinus
immediate

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◦ PMH is important in how you tx the patient more than ____

diagnosis

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History of Pain

PAIN

Inception Duration Frequency
Intensity Spontaneity Quality
Location Course
Relieving, Exacerbating factors

When the patient says he has pain you are asking these ____

questions

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History of Pain

Inception Duration Frequency

Previous Hx of Pain
Normal pulp: no
Reversible pulp: \_\_\_\_
Irreversible pulpitis: \_\_\_\_ (83%)
Partial necrosis: \_\_\_\_ (94%)
Total necrosis: \_\_\_\_ (79%)

80% of patients with Hx of pain manifest histologically ____ change

• From bender and settler
• What we say in the histology vs the answer to previous hx of pain
• Numbers are not important but the trend
• There is no previous hx of pain with normal pulp
• Reversible is yes or no
• Irreversible
◦ The percentage of pain is 83
• Partial necrosis - 94%
◦ Amount of pain increased
• Total necrosis
◦ Decreased
• Most of the pain that is associated in endodontitis the max amount of pain happens in ____
◦ The tooth is in ____ stage of dying
◦ The ____ is maximum at this point of tim

no/yes
yes
yes
yes
irreversible

partial necrosis or partial pulpititis
active
inflammation

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Severe Pain

Frequency of firing Number of nerves
Type of nerve fibers -> Intensity Spontaneity Quality

Histological Dx
Normal pulp: -
Reversible pulpitis: \_\_\_\_
Irreversilbe pulpitis: 18
Partial necrosis: \_\_\_\_
Total necrosis: 25

◦ Severity of pain do we have the same trend?
◦ Most with partial necrosis said it was very severe ◦ Max pain is in the partial necrosis stage of the pulp

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Diagnostic Tests & Interpretation

Mechanical
Sensitivity
Supplemental Radiographs

◦ The test we do 
‣ \_\_\_\_
‣ Palpation
‣ \_\_\_\_ for every case
‣ Heat only when the pt complains of heat

percussion

cold

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Extraoral Examination:

• Facial asymmetry 
• \_\_\_\_
• Palpation
-muscles of \_\_\_\_ 
-TMJ
-\_\_\_\_, trigger point
•Maximum opening
•\_\_\_\_; size, mobility, tenderness

• Suggestion: sit down
Moving around makes patients uncomfy
and that yo are in a rush 
• Start extra oral
◦ Look for facial asymmetry
◦ Any swelling
◦ Trauma - looking for changes in the eye
dropping or the blinking etc
◦ Observing the patients facial structure

pupil
mastication
pain
nodes

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Muscles of mastication

Masseter
Origin: ____
Insertion: ____
Description: ____

Temporalis
Origin: ____
Insertion: ____
Description: ____

Medial pterygoid
Origin: ____
Insertion: ____
Description: ____

Lateral pterygoid
Origin: ____
Insertion: ____
Description: ____

zygomatic arch
mandible
closes jaw

temporal bone
coronoid process
closes jaw

sphenoid, palatine, maxillary
inner (medial) surface of the ramus
closes jaw

sphenoid bone
mandibular condyle
opens protrudes jaw; side to side

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Muscles of mastication

• When the master is inflamed it causes pain as if it is coming from the ____
• Can have the patient clench the jaw and squeeze the masseter they get pain
◦ Can reproduce muscle pain that can be ____ to pain
• OS will take ____ and inject it in the master to see if they can relieve the pain the patient is
experiencing
◦ That is a DX test
• Or ____ the muscle

• More common is the ____
◦ One of the attachments of the medial pterygoid is maxilla
‣ Close to the teeth
‣ Behind the ____ on the palatal of the maxilla
‣ If any reason the patient has inflamed this - grinding or clenching, over extended etc they injure these muscles
◦ When this muscle is injured they think their teeth are ____
‣ Probably the attachment of the medial pterygoid on the palatal area
◦ Illicit this pain
‣ Rub on the inside and when you touch the attachment it will illicit the pain ◦ Refer these to OS

teeth
referred
anesthetic
squeeze

medial pterygoid
second molar
aching

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Lymph Nodes

• Lymph nodes: drain lymphatic fluid and inflammation
• They drain throughout the body and go and filter out into the vein, into the lungs, then back to the heart
• Three major nodes where most of the structure drain:
◦ ____
◦ ____
◦ ____
• Swollen lymph node feels like a KNOT or SWOLLEN gland under the border of the mandible
• When squeeze it–> hurts, its mobile

submandibular
deep cervical
superficial cervical

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Lymph Nodes • Similar inflammation can happen in superficial and deep lymph nodes, where most structures in head drains into • Severe inflammation in pulp will drain through the lymphatics into one of these three ◦ Very commonly drain into --> ____ lymph node Clincially: if there is swelling under a pts jaw • Diognosis: inflamed lymph node • Treatment: remove the inflammation ◦ Where is the inflammation? The ____ ◦ Not going to do anything to the lymph node, instead you treat the tooth with the inflammation ◦ Once you eliminate the inflammation --> the swelling in lymph node can go away ◦ Takes approximately ____ days for inflammation to go away ◦ Why is this important? ‣ To win over the pt because thats the the chief complaint! ◦ When Yoou do the root canal treatment, tell the pt to give the gland a week before this swelling goes away or they will be upset ‣ Its abouts a pt management!! --> address before the patient asks you about it

submandibular tooth 5-10

Lymph Nodes • Whats imp to know: about the submandibular lymph node • Most important lymph node that might need addressing is the submandibular, where most structures indrawn he and teeth drain into • Know what drains where! • Everything drains to the ____ ultimately • First of concern is the submandibular lymph node Mandibular teeth Drain backwards through the ____ canal

deep cervical | mandibular

Lymph Nodes Gingivae Mandibular lingual anterior segment: ____ 1. ____ of both arches 2. ____ gingivae 3. ____ of the mouth 4. ____ gingivae

submental buccal gingivae mandibular lingual floor maxillary palatal

Intraoral Examination: ``` Hard tissues: Tooth discoloration •____, erosion, developmental defects •Fractured teeth •____ •Defective restoration •____ discrepancies • Swelling ``` ``` Soft tissues: Color • ____ • Consistency • ____ ```

attrition caries occlusal texture contour

Sinus tracts Color, texture, consistency, contour of the soft tissues •Attachment apparatus •Path of least resistance: ____ •At least #35 GP cone • Sinus tract: looks something like this • Sinus tract = Natures way of dx something for you • Its a "give away" to what is causing the disease / inflammation • Does the tooth have to be ____ for sinus tract to occur? ◦ YES • Tooth is necrotic, its draining from the apex, filling bone around it with educate, exudate needs to be released ◦ Usually the path of LEAST resistance is ____ onto the buccal bone ◦ If you had device that pokes through sinus tract --> can lead you to tooth causing the problem! ◦ Use Gutta percha cone in practice, the type is important ‣ ____ GP with 0.04 taper ‣ Do not use smaller cone because it won't go through sinus tract ‣ Look at sinus tract: Where do you thread it? ‣ Find the opening or puncture through it ‣ Most people just feel sensation when poke on it with GP • If sensitize to pain, they may jump out of chair ◦ Use ____ on sinus tract and then perforate • Nice example of why you want to trace a sinus tract • Take Xray and can see both teeth are infected • Which tooth do you take care of? ◦ The one associated with pain and the one GP points to in sinus tract ◦ This one points to 9, NOT 10 ◦ Thus treat this ____ first!

buccal sulcus necrotic buccal plate 35 topical tooth

Sinus tracts * ____ GP will wrap around itself, it just rotates at tissue surface (can see on pic on RIGHT) * ____ GP has more strength to it so will go through (LEFT PIC)

smaller | 06

Palpation: Digital pressure, bimanual •Spongy, fluctuant, indurated Inflammation in the periodontal ligament (tooth) -> periodontal ligament (jaw bone) Useful for ____ molars than lowers since the thin overlying cortical bone. • Next you palpate! • Opened mouth, looked at ST, and focus on lower jaw • Palpation involves taking gloved finger and run it from the canine, around the gums, not on the teeth, to last tooth (molar) ◦ Before this: Tell pt tell when they feel pain! ◦ If pt's hands go up near 1st molar means --> something ____ the spot is inflamed ◦ Means bone is starting to resorb and Tooth next to it is necrotic and may be trying to drain, may be lesion there • DONT just do palpation of buccal, do the ____ as well! • If on Maxilla --> palate and buccal • Run the large surface, not just the tooth that is giving trouble, to figure out where it hurts

upper under lingual

``` Percussion: •Fingernail, blunt handle of mouth mirror •Facial, occlusal, lingual side •Occlusion, trauma, sinusitis, periodontal disease, pulpal disease ``` Inflammation in the ____ Degree of response is ____ related to the degree of inflammation Percussion: Means Banging the tooth Cause pain by tapping on the tooth What causes the pain? ____ ◦ It does NOT have to be just at the ____ Even if theres inflammation along the root, it is draining out in the PDL, there will be tenderness ◦ You are looking at Periradiular inflammation To make sure you illicit possible pain from all portions of PDL ◦ Tap on the tooth Vertically and Tap on the tooth horizontally ALWAYS tap on tooth you think is problem + 2 other ____ teeth!

PDL directly apex normal

Percussion Histologically, apical pulp tissue -- PDL Endotoxin, cytotoxic materials, and bacteria emanating from the root apex. But, where chronic PA inflammation is present, percussion testing often yields a ____ response If you cause pain to someone, how do you go about doing this? Do you want to run tests on something that does NOT cause pain first --> ____ ◦ Do tests on the ____ first where they do not experience pain! ◦ ◦ Tell you're its you are testing normal teeth first then warn pt before you approach the tooth that may illcit pain ‣ If they are prepared for pain they are more forgiving Talk the pt through the dx test If you don't warn them you lose the pts TRUST ‣ ‣ ◦ Why pain on percussion --> due to apex inflammation in the ____ tap the tooth and it hurts

negative YES baseline PDL

Mobility: Tests: Inflammation of the PDL How: ____ direction, depressibility within its alveolus Cause: Acute periradicular ____, root fracture, recent trauma, chronic ____, habits, and orthodontic tooth movement Result: 1: Barely perceptible ____ movement 2: < ____mm 3: > ____ mm ____ ± vertical depressibility

``` facial-lingual abscess bruxism horizontal 1 1 horizontal ```

Mobility: Do your teeth normally move? How to test this: use two ____ things not finger because your finger is depressible it self so may seem as if tooth is moving when its not Want to make sure its too ard things like mirrors You will see there there is some micromovement which is normal Grade 1: If the offending tooth is a little more loose then the other its grade I mobility Grade 2: Mobility about 1mm or so Grade 3: if tooth is mobile AND ____ (when push on top of tooth it move down) What causes this movement: Abscess, fracture, trauma, ortho (braces esp when bands are activated), bruxers and grinders (movement)

rigid | depressability

Periodontal Examination: •“____ the probe” •General periodontal health •____ in the sulcular defect and radiograph Periodontal: ____, gently sloping craters around multiple teeth Endodontic: isolated ____ loss (fracture/sinus tract) Perio exams You are not probing just the offending but probing the entire quad You must walk the probe, from Buccal to tooth of concern to the tooth behind it Walk probe because when the tooth is maybe fractured (vertical fracture - which won't show up on ____) Instead of pus draining on apex there is inflammation along fracture line/ bone loss there ◦ When bone loss around the fracture line: walk the probe --> you dip in from 2s to an 8

``` walk GP cone wide vertical X-ray ```

Sensitivity vs. Vitality Test Severing of ____ -> ____ function of death of nerves heat, cold, electric current test Temperature tests: When you do cold test you are testing ____ Heat test are testing ____ EPT is testing ____, C fibers do not repsond When you say an organ is vital what do you mean by that It means it still has a ____! When the tooth is vital ideally then we are testing for blood supply The three tests are testing for ____ So the actual terminology we should be using is ____ testing not vitality test Vitaliting is testing for ____ vessels Sensitivity tests the nerves Based on the response we are assuming that the tooth is vital and has a blood supply

blood vessel abnormal a delta a delta and c delta a delta blood supply nerves sensitivity blood

Thermal stimulus: Theory: ____ stimulus causes ____ of the fluid within the dentinal tubules

thermal | movement

Thermal Pulp Tests: Extreme temperature changes -> exciting pulpal -> ____ fibers Gradual temperature changes -> exciting pulpal -> ____ The sensory fibers of the pulp transmit only pain whether the pulp has been cooled or heated Hydrodynamic theory Cold test: When you out cold on the tooth, the fluid rushes out as it contracts, the odontoblastic process gets pushed out, around the odontoblastic process is a delta, a delta fiber gets stretched, and the pt feels a ____ shooting pain ◦ For the c fiber to be excited it isn't as immediate, its in pulp proper ◦ Cold test can cause severe shooting pain by exciting the ____ Change of temp has to go through ____ into ____ to excite a delta fibers

a-delta c fibers sharp a-delta enamel dentin

Thermal Pulp Tests: Cold -> ____ pain response; vasoconstriction -anoxia -> a-delta fiber ____, ____ effect Heat -> sudden temperature change -> rapid, ____ pain response dilation of blood vessels increase in pulpal pressure -> more ____ pain

a-delta cease cryogenic brief intense

Cold test: ``` CC: sensitivity to cold ____ air, water (triple syringe) •____ isolation and cold water bath •____ chief complaint ``` CC: no complaint to cold CO2 ____ •____ stick •Applied on tooth for 5 seconds or until pt feels pain.

directed rubberdam reproduce snow ice

Studies show that what tests shows you is not always what going on in tooth, and whats going on in tooth many not be reciprocated by these tests Two things we know for certainty History of ____ pain = need endo ◦ Max amount of pain = ____ ◦ For the rest, you are using your diagnostic skill - used to find where pain is coming from! For the Cold test you are eliciting ____ fibers ◦ When A delta is dead, do you get a response with cold test? ____ ‣ You might get a response from the ____ if you keep the cold there for long enough and it diffuses through it to make changes in the blood vessels When put something cold on your hand --> you see vasoconstriction or a white patch If cold test was cold enough that it diffused through pulp to Blood vessel, and cause VC and VD once you remove the cold...you CAN elicit a pain I you make a change in the blood vessels you can create pain

spontaneous partial necrosis a delta no c fibers

Heat test Hard to elicit pain ◦ When put hot on tooth, the tubular fluid doesn't move as quickly as when cold is on tooth ◦ Heat is diffusing heat from enamel to dental to pulp, and makes the BV expand If put heat on skin and and take it away = VD, it makes skin appear RED instead of white If you can diffuse the heart from your heat test into the pulp, and make the BV expand, the ____ will start to hurt ‣ ◦ ◦ ◦ ‣ The pain you feel is ____ throbbing pulsing! If pt is in the chair and says very sensitive to col what do you do first? Do cold test = ____ Do on ____ TOOTH first If not responsive: ____will go through a mummification - histological feature Any time the a delta fiber degenerates or mummifes you do not get a response from them

c fibers quickly normal a delta

``` Ethyl Chloride •-18.0° •Compressed spray •Used in ____ as a skin refrigerant. •No longer used for ____ testing because it has been found to be less effective ``` Used to use this, Not used in dentistry today, only used in medicine today On skin can lower temp to -18 degrees Thus it is not very effective for ____! (Boards question) ‣ ◦ ◦

medicine pulp dentistry

Dichlorodifluoromethane •R-12 •____ point of -21.6° F, •Used as a ____ and propellant in aerosol sprays •Prohibited by the Clean Air Act in the US on Jan 1, 1996 due to concerns about damage to the ____ layer.

boiling refrigerant ozone

``` 1,1,1,2 Tetrafluoroethane (TFE) •nonchlorofluorocarbon refrigerant •Green Endo-Ice •Boiling point (-30 °C, -15.1 ° F). ``` Endo ice: This is what we see in clinic Endo ice -30 degrees! ◦ If you take a cotton pellet and soak it with ends ice, you transfer -30 degrees to tooth and cause pain Whats wrong with this picture below? Cotton pellet is too big It is stimulating too many teeth, you want it to ONLY touch tooth you are ____ Other ppm: Where it is applied On posterior teeth you want to apply it on ____ SURFACE Anterior teeth: ____ Why these places? ‣ Enamel is the ____ there, and you are trying to move the fluid in the dental tubule Yo u want to transfer cold immediately ‣ In these areas the nerve fibers are the ____, illicit faster bigger response ‣ ‣

``` testing buccal incisal edge or incisal 1/3 thinnest max ```

TFE Do not spray it directly on the tooth as it can cause craze lines in the enamel Cotton wrapped on a q tip is wrapped too ____ Cold has to absorb in a pellet form and this can't get this to be as cold By the time you get to the tooth the temp is warm again You SHOULD: use ____ cotton in pellet on ____ surfaces on anterior ____ edges

tightly small buccal incisal

``` CO2 snow •Extremely cold (-77.7°C, -108°F) •____ •____ ( < 2 seconds) •Most ____ ``` Clinically, CO2 snow application give better test results than ____ the other test you can use is the CO2 snow This is used in Europe not FDA approved in the us The temp is -77 degrees Endo is -30 so twice as much Fuss et al 1986 ◦ Therefore, it is VERY effective in eliciting ____ and have to be more careful with this!

``` safe rapid effective ice water a delat ```

``` old testing - Full crowns Type of the material: • Gold • PFM •All-porcelain crown ``` Type of the thermal testing: •Ice stick •TFE •CO2 snow Cold test is just on the ____ not bathing the way the patient does Use ____ on the gums to clamp doesn't hurt (since can't use anesthesia before test) Squirt this on the tooth and see if the hand goes up keep the suction ready so you can take it away We are doing the cold test exactly the way pt does cold test at home! how? Pt drinks something cold and it hurts, by bathing ENTIRE tooth in cold In clinic only use a small amount of surface ◦ Use ____ if you CANT figure out where the pain is coming from ◦ Syringe with cold (if pt says cold makes them sensitive) or heat (if pt says heat irritates tooth) ◦ ◦ Most accurate way to ____ the pain the patient is experiencing

surface benzocaine rubberdam reproduce

``` Heat Test: Rubber Dam Isolation •Less ____ •____ for 5 seconds •most ____ •____ all surfaces of the teeth. ```

convenient bathing accurate cools

Electric Stimulus Theory: EPT evokes pain response due to ____ movement Electric conductivity causes an ionic imbalance across the neural membrane causing ____ to fire off, eventual neuronal perception in the cortex So in diagnostic tests last time we spoke about: cold test & heat test. The last test that we left in terms of sensibility of the tooth is Electric Pulp Test (EPT). EPT as the name suggests, instead of putting cold or heat on the tooth, you're actually zapping the tooth. You're sending out electrical impulses to the tooth, so when you excite the tooth with electricity, what part of the pulp you're trying to excite? ____ fibers or the ____ not the BVs. You're trying to excite the nerve fibers which will give a response in terms of tingling, zinging or may be pain depends on how the patient perceives it. So you are trying to stimulate the A-delta fibers, it is usually ____ fibers that will respond to EPT not C and we will talk about that as well.

``` ionic action potential a-delta nerves a-delta ```

Electrical Pulp Test (EPT) Analytic Technology Pulp Tester Speed of current flow rate increase Digital reading (indicating current flow rate) 0-80 (15-330 V) Latex glove: ____ - Safe with ____ The EPT machine looks like this, so say you go to the IMS window and say "Please issue me the PET machine" they are going to give you this white little box which is attached with a cord to this metal handedpiece and a little probe which is sterilized in a bag. This thing which is just the back of a paper cup and the blue that you see on the top is the toothpaste that is dispensed wherever the medication or anesthesia is dispensed, so this is your conduction ____, because remember we are dealing with electricity here. So what you're going to do is you're going to put this probe, insert it into this end of the handpiece "there is a little light here it's a green pulp". So you will ask the patient to hold the metal portion of this probe while you hold the same metal portion with your gloved hand. So the patient doesn't have ____, patient's holding the metal portion with their bare ____ because you want the circuit to ____ but you will have a gloved hand because you don't want the electrical to go through you.

non-conducting pacemarkers medium gloves hand complete

EPT ``` How: • ____ field: gauze, saliva ejector • A ____ or celluloid strips • Sensations of heat or tingling felt • lingual and facial surfaces • ____ times (1-2 minutes recovery time), average taken • Significant variation in response suggests a ____ reading • Enamel ____ influences response time (thin in ____ vs. thick ____) ```

``` dry rubber dam 2-3 false thickness anterior posteriorly ```

EPT Go to the tooth you are going to be testing, dry the area out, you don't want saliva in that area let’s say if you have saliva poured into 8 and 9, if you stimulate 9 through the saliva, 8 will get stimulated as well because it is all conducting. So you get the area dry and you concentrating on the tooth you are going to work on. let’s say it's a posterior tooth has MOD amalgam filling, what does amalgam do? Silver? it ____. Through the MOD, it can actually stimulate the ____ teeth as well so in those cases you can use small pieces of ____, and you can insert it in the M and D contacts of that tooth so you don’t conduct the electrical pulses. let's say it's an ant with a composite restoration, you don’t really need to do that. If it is a conducting restoration, you need to have some sort of material that will not conduct the electricity.

conducts neighboring rubber dam

EPT Then you will take that blue paste apply it to the tooth ,place the blue proportion of that EBT on that blue paste have the patient hold on to the ____ portion and as soon as the conduction starts as soon as the circuit is built, you will start to see a reading appear on this little panel. the light will light up, the reading on the blue panel will go from 0 to either 60 or 80 depending on the machine on this machine that is a 60. so what's happening when it goes from 0 to 60? it's sending out ____ voltage of currents. so patient might not feel anything at 0 1 2 3 4 5 6 7 8 and about 18 19 20 the hand goes up. Remember we spoke about the hand response? We ask the patient to raise their left hand when they feel something. So when the hand goes up, you take the metal portion or metal probe off the tooth, disconnect that electrical circuit that you've created. Does anybody know what that number means? it really doesn't mean anything as long as the patient gives a response somewhere along that 0 to 60 or 80 whatever is the highest number is. The

metal | larger

Interpretation: Results • Fails to provide any information about the ____ supply to the pulp, which is the true determinant of pulp vitality. • Numerical values ____. So you stimulated a nerve inside the pulp chamber by giving it electrical stimulation. If the patient response at 10 or the patient response at 20,30,40,50 it doesn't mean anything. It doesn't give you any sign of inflammation, it just tells you whether there is a nerve ____ or a nerve piece A delta fibers in the tooth.

vascular meaningless response

Interpretation: Results A-fibers/pulp + = ____ sensory fibers - = ____ sensory fibers irreversible pulpitis: may be ____ (distribution & larger ____ than C fibres; conduction speed and ____ sheath. C fibres have a ____ threshold, and would need a stronger electric current to stimulate them.) Sometimes when you apply that EPT on the tooth and you get no response and suddenly towards the end ‘somewhere 59-60 if it’s a 60 machine or 79-80 if it's a 80 machine” if the patient’s hand goes up, the electrical current that you sent through the tooth could have gone through the tooth to the ____ and the PDL could have responded. So that would be the only thing you would be concerned about in terms of time or that number, a response too ____ to the last number on your machine could be coming from somewhere else like the PDL instead of the ____. So, the number doesn't really mean anything you're just looking for nerve inside the tooth.

``` vital no +/- diameter myelin higher ``` PDL close pulp

Interpretation: False Positive 28% of teeth with necrotic pulps tested positive to ____, and more than half of those with partially necrotic pulps were ____. EPT only excites ____ nerves Overall localization accuracy of 82% (1035 stimulation test) This study was conducted and they said 28% of teeth which are generally testing necrotic (which means your cold and heat response was negative) can respond ____ to EPT. What does that mean? that means that there might still be some pieces of the nerve in that necrotic pulp that might get stimulated with your EBT. So you should probably go with the diagnosis of necrosis based on the ____ situation not just your EBT results. So your cold and heat test is negative it's a necrotic tooth, decay is large, there is a large lesion at the tip of the tooth even if your EBT gives a ____ response because 28% might be false positive. 

``` EPT responsive A-delta positively clinical positive ```

Interpretation: Reasoning: False Positive: • ____ • Saliva conducting stimuli to gingivae • ____ restorations conducting to adjacent teeth • ____ necrosis conducting stimulus to the attachment apparatus • ____ teeth ____ pulp > EPT > Pain upon access Activation of ____ that do not respond to the pulp tester

``` anxiety metallic liquefactive multirooted necrotic C-fibers ```

Interpretation: So the false positive response can be: when the patient's anxious. Remember how we spoke about last time that you should always test a normal tooth first so that the patient knows what to expect so that when you get to the offending tooth the response is what it should be. so the patient is anxious you just touch the metal portion on the tooth and then suddenly the hand is up and "I'm feeling something" that could be a false positive response. if you didn't ____ the tooth enough and is saliva conducting to either the gingival or to the neighboring teeth you can get a false positive response. Is there's metal Restorations connecting to the neighboring teeth, you can get a false positive There's this kind of necrosis "liquefaction necrosis" when it is not true necrosis where the the tissues completely destroyed, when there's actually liquefaction happening in the necrotic tooth you can get conduction from EBT to the liquefied tissue to the PDL and you can get a false response. it is not coming from the pulp, it's actually coming from ____ Let's say if it's a molar, the pulp in the mesial root is necrotic, the pulp in the distal root is still ____, so if it's a multi rooted tooth you can get response from one of the roots which still has some vital pulp.

dry PDL alive

Interpretation: Reasoning: False Positive: - ____ conducting stimuli to gingivae - liquefactive necrosis conducting stimulus to the ____ ____ electrical current is needed to activate PDL nerve fibers: 60-80

saliva attachment apparatus higher

Interpretation: ``` Reasoning: False negative: • Premedication with ____, alcohol • Immature teeth • ____ • Poor contact the tooth • Inadequate ____ • Partial necrosis with vital apical tissue • ____ pulps • High pain thresholds ``` If the patient is drugged, patient is high, patient had a few shots alcohol before he walked in and they do that quite a few. If something, that alcohol will numb their pain they won't be as nervous it's actually the opposite, they're far more ____ so you can get an anxiety false positive response or if they're truly high you can get a false negative response where they don't feel anything when you're doing the test on them. We're going to talk about immature teeth and Trauma later in May when we meet again so trauma ____ teeth can give you a false negative response. You didn't put adequate amount of ____ so that it would conduct electricity that'll give you a false negative response.

drugs trauma media atrophied anxious immature toothpaste

Interpretations If you didn't touch the tooth properly you're little few mm away that's not going to give you a response. when it is partially necrotic, say the coronal portion of the tooth is necrotic and there is still some vital tissue in the ____, it can give you a false negative response as well. This is important Atrophied pulp means ____ pulp have you guys seen an x-ray where you look at the X-ray you see the tooth structure and you see a dark area within the pulp which is your pulp chamber and then you have another tooth where that pop chamber is completely white it's called calcified right so in those calcified teeth also you can get false negative responses. or the patient has a ____ pain threshold

apex calcified higher

Interpretation: Reasoning: False negative: ____ teeth Myelinated nerve fibers-maximum ____ years after tooth eruption 2.Lack of development of the ____ in the Pulp-dentin border-final stages of root formation 3.____ Pulp space-impedance So when a tooth erupts in the mouth, how long does the root take to close? up to three years. Until the root closes in those three years, do you know the pulp and dentin junction has the odontoblast and the ____ fibers around it. That area is called the Plexus of Raschkow, that nerve bundle at the dentin pulp junction does not mature adequately till the root closes which means if you're trying to do an EBT cold or heat test on an open Apex your test are not reliable. So immature teeth testing is actually really hard number one your testing ____ whose response can be questionable and the other problem is the test itself might not get you an adequate adequate response

immature 5 raschkow plexus large a delta children

Immature teeth Here is a study that was done. They could get a positive EPT response on immature teeth with ____ Apex in 72% of the cases ____ when the Apex was open only 11% of the cases. That doesn't mean that there's no nerve it's just that the nerve plexus is not ____ enough to respond

closed open mature

Interpretation: Cervical 1/3 Average calibration of response threshold: ____ Middle 1/3 Average calibration of response threshold: ____ Incisal 1/3 Average calibration of response threshold: ____ Incisal edge Average calibration of response threshold: ____ ____ teeth > mandibular teeth ____ > central incisors Here's another thing, I told you the number doesn't mean anything in terms of inflammation in the pulp but it does mean when the electricity is ____ enough for the pulp to be stimulated. so when you go from 0 to 20 at 20 the electrical stimulation to the tooth is much higher than what it is at one or two. This chart tells you that you can get a response from an anterior tooth at the incisal edge at a lower number than when you are at the ____ 1/3 and what basically that tells you is that if you're going to do EPT or even cold test, do it in the ____ edge where the number of nerves are maximum, the enamel is really thin and whatever you're trying to conduct whether it's electrical or cold, it goes faster to the pulp and where do you do it on the molars? you would do it on the ____ 1/3 of the ____ surfaces because this's where the enamel is the thinnest

35. 91 31. 44 28. 51 21. 81 maxillary lateral incisors ``` strong cervical incisal edge middle buccal ```

Interpretation: Highest concentration of nerves in the pulp horn - ____, ____ Direction of dentinal tubules - ____ Enamel thickness - ____, mandibular anteriors

incisal edge incisal 1/3 incisal edge incisal edge

Pulse Oximetry: - evaluates oxygen ____ of tissues - additional research needed for clinical use We spoke about this in the beginning of the session as well are testing nerves and when you say a tissue is vital that means it's got a blood supply but none of our tests so far are testing for blood supply. This is similar to the regular oximetry used o measure the oxygenation of the blood that is running through your finger. people who are into invention have tried to come up with an instrument which we could use clinically to see if there is blood supply in the tooth and that's called a pulse oximetry however it's cumbersome there're ____ from the gingiva it's very difficult to ____ so we don't use it if it's not available to us and Clinics the reason this slide is put in there is because that is a board question "the only equipment that we know of which will test blood supply is the ____ Machine however it is not used in clinic"

false positive isolate pulse oximetry

Heat Test: •Temporary stopping (GP in 30 inch stick): +75.0° •Light coating of petrolatum •____ over a flame until it becomes soft and just begins to glisten (Grossman’s method) •response less than 2 seconds A ____-second application -> pulpodentinal junction increase < 2°C therefore it is ____ that damage will occur to the pulp. Heat test: ◦ ◦ ◦ ◦ Done when the patient complains of heat Hard to get a response from a normal tooth with a heat test Have to transmit a change of ____ degree centigrade from Pulp-dentin junction into proper pulp on normal tooth for ____ to get activated If inflammation - there is allodynia, heat that doesn't cause pain normally, does cause pain here

warmed 5 unlikely 2 C fiber

Heat Test: Hot GP application give better test results than ____ ____ superior Heat test with gutta percha stick Yo u wipe the tooth dry, vasoline the tooth, heat GP stick over a fire until it becomes shiny ◦ (tiny means means its at right temperature) and then you put the hot stick on the buccal surface of the tooth ‣ Whats the reason for the ____? Transmitting the heat from soft into the pulp ‣ ‣ If you forget this you cook the pulp! So its doesn't ____ to tooth! ‣

hot water RDI and water bath vasoline cook

Heat Test: B&L SuperEndo-alpha II Heated Tip This black handle has metal tip at one end. When press button it shows how hot tip will be. Touch hot tip to tooth. Dint touch on lip or the gum or will burn it! Use this for ____ test on the tooth.

heat

Interpretation No response: Nonvital pulp ____ negative: excessive calcification, immature ____, recent trauma, patient ____ Mild-Moderate: subside within 1-2 seconds ____ Strong momentary painful response for 1-2 seconds ____ Moderate-strong painful response, lingers for several seconds or longe ____

false apex premedication within normal limits reversible pulpitis irreversible pulpitis

This is a review of responses of tests. If you put cold on tooth but get NO response. What does this mean endodontically? The tooth is dead --> the ____ fibers are gone ◦ Other things can cause NO response: BUT can get false negative responses if pulp is ____ That is because there is no fluid movement in dentinal tubules to move, which is responsible to causing pain Cannot get positive response to! ____ test from calcification If the patient has taken 800mg of ibuprofen then your tests with be off This is because the ____ is reduced and dx is not gonna be accurate! No response: means tooth is ____ unless it is a false negative Mild: moderate response that goes away with the stimulus: WNL Slightly stronger response: (hand stays up awhile when test it) reversible pulpits Mod - strong: irreversible pulpitits (Hand goes up quicker and stays there and tooth begins ____) this needs an end procedure! Diagnosis is an art and a science. Science: this is what I am explaining to you The art is what you experience when you do diagnoses again and again - you can ◦ read their eyes, faces, and moves they make

``` a delta calcified cold inflammation crotic pulsing ```

If you test teeth, how long should you wait in between tests of each of the teeth - normal versus diseased tooth ____ some time and allow them to close mouth, and allow it to go back to ◦ homeostasis NEVER go one ____ to the other, it also confuses diagnoses as well ◦

wait | tooth