Visual Inspection

Clinical examination specifically for an endodontic diagnosis will focus on two areas: causative factors in the teeth (pulpal inflammation, infection, etc.) and signs of periapical pathosis in the soft tissues due to spread of an inflammatory/infectious process from the pulp.^1,2 All of the teeth on the side of pain should be visually inspected. Gross caries is an obvious etiology for painful symptoms. Occasionally in a case of spontaneous pain, gross caries may be observed in a tooth, almost invariably a molar, in the opposing arch from where the pain has been felt. Further testing in such a case often indicates that the teeth in the area of felt pain are normal, whereas the opposing carious tooth is the source of the referred pain.

CLINICAL PROBLEM

Problem

A 52-year-old male was seen on an emergency basis. His chief complaint was of acute, spontaneous pain episodes in the mandibular left molar area (Fig. 1-1, A). Visual examination revealed no caries or fracture lines in either the left maxillary or mandibular teeth. There was a very large amalgam restoration in the mandibular first molar, which was the area where the patient felt the pain was originating. Thermal sensibility (pulp) tests, however, elicited normal responses from all teeth in this area.

FIGURE 1-1 A, Left mandibular molars respond normally to thermal tests. B, Maxillary second molar with evidence of gross caries.

Solution

Failure to reproduce the patient’s chief complaint during the examination of this quadrant of teeth resulted in conducting further tests in other areas of the left side. Further tests were then conducted on the opposing teeth. The heat test elicited an acute, severe painful response on the maxillary second molar. A radiograph of this area revealed gross caries (see Fig. 1-1, B). Although there was no visual evidence of caries clinically, on removal of the occlusal composite resin, gross marginal leakage was apparent. Root canal treatment was indicated only on the maxillary second molar.

Another important process in the clinical examination is to search for the presence of coronal fracture lines.⁵ The majority of fractures occur in a mesial-distal direction, and frequently these are obscured by coronal restorations (Fig. 1-2). It is often possible to observe them only on the intact marginal ridges, but they may extend to or below the level of crestal bone on the interproximal surface (Fig. 1-3). Fractures may also be observed on the buccal or lingual surfaces.²⁶ Two fracture lines on different surfaces may be evidence of a complete cusp fracture. For example, the combination of a deep lingual fracture line in the lingual groove of a mandibular molar and a fracture line on the distal marginal ridge distal could indicate the fracture of the distal lingual cusp, which is a common factor in the initiation of pulpal inflammation (Fig. 1-4).

FIGURE 1-2 Coronal fracture evident on intact marginal ridges. The mesial fracture line is obvious (black arrows). The distal extension of the same fracture is not as apparent but is visible (red arrow).

FIGURE 1-3 A, Coronal fracture extending over distal marginal ridge. B, Periodontal defect from extension of crack below crestal bone (arrows).

FIGURE 1-4 A, Fracture lines evident on distal marginal ridge and lingual developmental groove of mandibular second molar. B, In this case, the fracture resulted in complete separation of the cusp from the crown.

The soft tissues should be examined for physical signs of redness and swelling that may indicate that the periapical tissues have become inflamed or infected. Typically these specific physical signs would be evidence of a sinus tract, local swelling over the apices, or regional swelling (Fig. 1-5). Discoloration and edema may also be clues in a site of recent acute infection. In view of the original complaint of the patient, the clinician must be careful to avoid being misled by the accidental discovery of additional problems. For example, if the original complaint included a current history of acute thermal sensitivity, the visual observation of a sinus tract in the alveolar mucosa or attached gingiva on a single-canal tooth may be evidence of a pulpal problem, but it would probably not be the source of the symptoms for which the patient is seeking treatment. In this situation, the patient may have at least two distinct problems.

FIGURE 1-5 Swelling resulting from an acute periapical abscess.

Occasionally there may be signs of infection that are likely to be the source of the patient’s complaint but unlikely to be of pulpal or periapical origin. Pericoronitis around a partially erupted third molar is usually recognizable owing to its location; an endodontic problem with the second molar may have to be ruled out (Fig. 1-6). Much more common are periodontal abscesses, which may be more difficult to differentiate from periapical abscesses if periodontal disease is evident throughout the dentition.^3,14 This diagnostic problem will be discussed further in the subsequent section on periodontal probing.

FIGURE 1-6 Pericoronitis associated with a partially erupted third molar (arrow).

The clinical examination is conducted with a series of instruments and techniques that might be considered the “tools of problem solving.” Each test or assessment technique can reveal a clue that may impact or confirm the ultimate diagnosis. Seldom will it be necessary to do all of the tests or techniques listed, but it is equally important not to jump to conclusions too early in difficult diagnostic cases. The process of clinical examination is intended to both identify the source of the symptoms or observed pathosis and to rule out pathosis on adjacent teeth. It may be difficult in some cases to reproduce reported symptoms, but it often will be possible to reach a confident opinion about the normality of certain teeth, thereby reaching a diagnosis through the process of elimination.

During a clinical examination, data are gathered using a multitude of tests and evaluative procedures. While some tests will focus on the status of the pulp, others will be used to ascertain the extent of the spread of pulp inflammation or infection to the supporting periodontium. At times, it is difficult to separate information that is pulpally related from information related to extension of the disease process or periapically related. It is the intent of this first chapter to focus on the gathering of key information that will initially provide evidence of pulpal status. Other findings gleaned in this problem-solving process must be correlated and integrated with a thorough examination of the supporting periodontium, along with quality radiographs. These data will then be integrated into a periapical diagnosis that will be addressed in Chapter 3.

Use of the Explorer

For diagnostic purposes, the No. 23 explorer or the DG16 endodontic explorer (both explorers can feature a No. 17 tip when the instruments are double ended) are useful for the detection of caries, open restorative margins, fractures, loose cusps, and fracture lines (Fig. 1-7). Interproximally, the extent of caries buccal lingually can be ascertained. If a cracked tooth is located in the area of pain, it is useful to explore the interproximal surface of the tooth with a fine No. 17 explorer (Fig. 1-8). Often it is possible to feel the presence of a deep fracture line and follow it vertically along the proximal surface. Obviously, the more apical the fracture is felt, the more likely there is pulpal involvement. If the fracture extends below crestal bone, periodontal breakdown may also occur, a finding with serious prognostic implications. This will be discussed in more detail in the section on periodontal probing and also in Chapter 3 on radiographic interpretation.

FIGURE 1-7 No. 23 explorer (left) and DG 16 endodontic explorer (right).

FIGURE 1-8 A, No. 17 explorer. B, Use of the No. 17 explorer to detect vertical fractures in the crown. C, Use of the No. 17 explorer interproximally for the detection of fractures.

Palpation

One of the most informative but often overlooked evaluative procedures of the clinical examination is palpation. While not crucial for a pulpal diagnosis, for teeth with pulpal necrosis, palpation soreness or pain may reveal the presence of inflammation associated with periapical periodontitis.¹⁰ Reflecting on the anatomy of this environment is important in the interpretation of findings in this examination. Teeth with roots that lie close to the surface of the alveolar process will more likely exhibit palpation sensitivity or tenderness. Roots covered by relatively thin labial plates of bone or no bone at all are usually in the maxilla, with the apices of the central incisors, the canines, the buccal root of the first premolar, and the buccal roots of the molars often located anatomically superficial to the bony surface.¹² Examination of teeth in human skulls indicates that fenestration of the apex or sections of the root surface is common in the absence of pathosis (Fig. 1-9).⁸ Periapical lesions of teeth in other areas are less likely to exhibit palpation tenderness, owing to the thickness of the buccal plate or the external oblique ridge in the case of the mandibular molars (Fig. 1-10).¹² Nevertheless, in conditions of an acute periapical abscess, palpation tenderness, local swelling, and drainage through the gingival sulcus are not unusual even where the buccal bone is very thick.

FIGURE 1-9 Fenestration is a normal anatomic finding.

FIGURE 1-10 Apices of mandibular molars covered with thick, dense cortical bone. Palpation signs are less common in this area.

Percussion

Pain or tenderness to tapping on a tooth (percussion) is not crucial to a pulpal diagnosis but is symptomatic of three other conditions. It may be a sequela of trauma, which applies to virtually all anterior teeth and is easy to identify by the history. A root canal procedure may not be indicated, because there may be no pulpal damage. Sensibility testing (formerly known as vitality testing) would be indicated. There may or may not be concomitant palpation tenderness with traumatized teeth, but if palpation tenderness is found, it will usually not be confined to the region over the apex.

Second, tenderness to percussion may be the result of periapical inflammation due to either a necrotic or an acutely inflamed pulp.^1,10 In these cases, concomitant palpation tenderness may or may not be found only over the apices. Depending on the acuteness or chronicity of the underlying pathosis, both the percussion tenderness and concomitant palpation tenderness can be either mild or extremely acute. Included in this category are teeth that have coronal fractures, since it is the pulp that becomes painful from the flexing of the cracked cusp. However, sensibility tests would be necessary to establish a pulp diagnosis.

Third, tenderness to percussion may be a symptom of occlusal trauma, most often the result of nocturnal clenching or bruxing.¹ The presence of a concomitant tenderness to palpation with this condition is rare. Furthermore, the pulps of affected teeth respond normally to sensibility testing. It is common to find more than one tooth equally sensitive and a history of episodes of discomfort separated by intervals of complete comfort. The reader is referred to Chapter 6 for additional information on this topic.

Percussion t/>