Examination Technique

A thorough examination is necessary to obtain a correct clinical endodontic diagnosis. The various steps during the examination are:

1. Anamnesis (patient's history): The patient's history is always important. Usually it is wise to ask about the patient's local history and complaints first, and after that get the general anamnesic information. It is better to write too much than too little - please remember that the chart is a legal document.

  1. general
  2. local

LISTEN TO THE PATIENT !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

2. Visual examination--intra- and extra-oral inspection: Look for swellings, both extraorally and intraorally.

3. Clinical examination: "Mirror and explorer." Look for caries, missing fillings, cracks, discolorations, fistulas etc. Palpation will reveal tenderness in extraoral as well as intraoral tissues. Palpate regional lymph nodes, crowns of teeth, periapical areas (apical tenderness) both facially and lingually or palatally. Percussion is carried out gently with a solid instrument, e.g., mirror handle. A positive answer reveals a tenderness in periradicular tissues.

4. Radiographic examination: Radiographic examination is a valuable diagnostic tool. Periapical inflammations usually result in changes in the bony tissue and these can be diagnosed radiographically. In the early stages of a periapical inflammation the bone resorption may not have reached a size that is necessary for radiographic "visibility". Further information can be gained from the radiograph by means of radiopaque materials, e.g., a gutta-percha point placed in a fistula. (This is a way of tracing the origin of the fistula or sinus tract - fistulography).

5. Sensitivity testing: Test the ability of the pulpal nerves to register stimulation. A possible answer can mostly be considered as a sign of pulp vitality (functioning circulation, etc.). Sensitivity testing can be carried out in different ways:

  1. Mechanical stimulation. During excavation of caries, or during probing or air-spraying of a dentin surface it is usually possible to get a good opinion of the sensitivity of the dentin. In other words, do not anesthetize the tooth before you know whether it is vital or not.
  2. Thermal testing. (The following responses refer to vital, healthy teeth):
    1. Cold. When ethyl chloride or ice are applied to the tooth, the patient will experience a slight sharp pain of short duration.
    2. Heat. Heated base plate gutta-percha applied to the tooth will give a slight pain reaction. This test is mainly used to provoke a pain reaction during examination of pulpal inflammation. Note: Apply the base plate gutta-percha to a wet tooth surface. This will facilitate the removal of the gutta-percha.
  3. Electric pulp testing. This test can be performed by means of a lot of different brands of pulp testers. The tooth must be absolutely dry or the current can reach periodontal tissues and give false responses. Basically only "yes and no" answers should be registered (compare with the thermal tests). (The various brands of electric pulp testers give numerical values. However, these do not mean that "one tooth is more vital than another".) One drawback with electric pulp testing is that the current can pass a necrotic coronal portion of the pulp into a vital root pulp. Also, a positive response may be received from a multirooted tooth where only one root canal contains vital tissue. Thus it is possible to get false positive reactions. This is rare when you use mechanical or thermal tests.

Note: Mechanical testing is often the best way. If there is a carious lesion, start excavating the decay without anesthesia--if the pulp is vital you will soon get a response. (In some instances a test cavity -you drill intentionally into the tooth to get a response - has to be made in order to make an evaluation of tooth vitality possible). If it is not possible to carry out mechanical testing continue to other test methods, e.g., cold test and electric pulp test. If possible use a combination of tests such as cold and electric tests.

*Always start the test procedure by testing an "innocent" tooth.* This will make it possible to evaluate the patient's reaction to the test procedure.

Information from the patient in combination with clinical and/or radiographic findings will give the information on which the diagnoses will be based.