Art and Science of Diagnosis

Diagnosis is the art and science of detecting and distinguishing deviations from health and the cause and nature thereof. The purpose of a diagnosis is to determine what problem the patient is having and why the patient is having that problem. Ultimately, this will directly relate to what treatment, if any, will be necessary. No appropriate treatment recommendation can be made until all of the whys are answered. Therefore, careful data gathering as well as a planned, methodical, and systematic approach to this investigatory process is crucial.

Gathering objective data and obtaining subjective findings are not enough to formulate an accurate clinical diagnosis. The data must be interpreted and processed to determine what information is significant, and what information might be questionable. The facts need to be collected with an active dialogue between the clinician and the patient, with the clinician asking the right questions and carefully interpreting the answers. In essence, the process of determining the existence of an oral pathosis is the culmination of the art and science of making an accurate diagnosis.

The process of making a diagnosis can be divided into five stages:

  • 1.

    The patient tells the clinician the reasons for seeking advice.

  • 2.

    The clinician questions the patient about the symptoms and history that led to the visit.

  • 3.

    The clinician performs objective clinical tests.

  • 4.

    The clinician correlates the objective findings with the subjective details and creates a tentative list of differential diagnoses.

  • 5.

    The clinician formulates a definitive diagnosis.

This information is accumulated by means of an organized and systematic approach that requires considerable clinical judgment. The clinician must be able to approach the problem by crafting what questions to ask the patient and how to ask these pertinent questions. Careful listening is paramount to begin painting the picture that details the patient’s complaint. These subjective findings combined with results of diagnostic tests provide the critical information needed to establish the diagnosis.

Neither the art nor the science is effective alone. Establishing a differential diagnosis in endodontics requires a unique blend of knowledge, skills, and ability to interpret and interact with a patient in real time. Questioning, listening, testing, interpreting, and finally answering the ultimate question of why will lead to an accurate diagnosis and in turn result in a more successful treatment plan.

Chief Complaint

On arrival for a dental consultation, the patient should complete a thorough registration that includes information pertaining to medical and dental history ( Figs. 1-1 and 1-2 ). This should be signed and dated by the patient, as well as initialed by the clinician as verification that all of the submitted information has been reviewed (see Chapter 29 for more information).

FIG. 1-1
Dental history form that also allows the patient to record pain experience in an organized and descriptive manner.

FIG. 1-2
Succinct, comprehensive medical history form designed to provide insight into systemic conditions that could produce or affect the patient’s symptoms, mandate alterations in treatment modality, or change the treatment plan.

The reasons patients give for consulting with a clinician are often as important as the diagnostic tests performed. Their remarks serve as initial important clues that will help the clinician to formulate a correct diagnosis. Without these direct and unbiased comments, objective findings may lead to an incorrect diagnosis. The clinician may find a dental pathosis, but it may not contribute to the pathologic condition that mediates the patient’s chief complaint. Investigating these complaints may indicate that the patient’s concerns are related to a medical condition or to recent dental treatment. Certain patients may even receive initial emergency treatment for pulpal or periapical symptoms in a general hospital. On occasion, the chief complaint is simply that another clinician correctly or incorrectly advised the patient that he or she had a dental problem, with the patient not necessarily having any symptoms or any objective pathosis. Therefore, the clinician must pay close attention to the actual expressed complaint, determine the chronology of events that led to this complaint, and question the patient about other pertinent issues, including medical and dental history. For future reference and in order to ascertain a correct diagnosis, the patient’s chief complaint should be properly documented, using the patient’s own words.

Medical History

The clinician is responsible for taking a proper medical history from every patient who presents for treatment. Numerous examples of medical history forms are available from a variety of sources, or clinicians may choose to customize their own forms. After the form is completed by the patient, or by the parent or guardian in the case of a minor, the clinician should review the responses with the patient, parent, or guardian and then initial the medical history form to indicate that this review has been done. The patient “of record” should be questioned at each treatment visit to determine whether there have been any changes in the patient’s medical history or medications. A more thorough and complete update of the patient’s medical history should be taken if the patient has not been seen for over a year.

Baseline blood pressure and pulse should be recorded for the patient at each treatment visit. Elevation in blood pressure or a rapid pulse rate may indicate an anxious patient who may require a stress reduction protocol, or it may indicate that the patient has hypertension or other cardiovascular health problems. Referral to a physician or medical facility may be indicated. It is imperative that vital signs be gathered at each treatment visit for any patient with a history of major medical problems. The temperature of patients presenting with subjective fever or any signs or symptoms of a dental infection should be taken.

The clinician should evaluate a patient’s response to the health questionnaire from two perspectives: (1) those medical conditions and current medications that will necessitate altering the manner in which dental care will be provided and (2) those medical conditions that may have oral manifestations or mimic dental pathosis.

Patients with serious medical conditions may require either a modification in the manner in which the dental care will be delivered or a modification in the dental treatment plan ( Box 1-1 ). In addition, the clinician should be aware if the patient has any drug allergies or interactions, allergies to dental products, an artificial joint prosthesis, organ transplants, or is taking medications that may negatively interact with common local anesthetics, analgesics, sedatives, and antibiotics. This may seem overwhelming, but it emphasizes the importance of obtaining a thorough and accurate medical history while considering the various medical conditions and dental treatment modifications that may be necessary before dental treatment is provided.

Box 1-1
Medical Conditions That Warrant Modification of Dental Care or Treatment

  • Cardiovascular: High- and moderate-risk categories of endocarditis, pathologic heart murmurs, hypertension, unstable angina pectoris, recent myocardial infarction, cardiac arrhythmias, poorly managed congestive heart failure

  • Pulmonary: Chronic obstructive pulmonary disease, asthma, tuberculosis

  • Gastrointestinal and renal: End-stage renal disease; hemodialysis; viral hepatitis (types B, C, D, and E); alcoholic liver disease; peptic ulcer disease; inflammatory bowel disease; pseudomembranous colitis

  • Hematologic: Sexually transmitted diseases, HIV and AIDS, diabetes mellitus, adrenal insufficiency, hyperthyroidism and hypothyroidism, pregnancy, bleeding disorders, cancer and leukemia, osteoarthritis and rheumatoid arthritis, systemic lupus erythematosus

  • Neurologic: Cerebrovascular accident, seizure disorders, anxiety, depression and bipolar disorders, presence or history of drug or alcohol abuse, Alzheimer disease, schizophrenia, eating disorders, neuralgias, multiple sclerosis, Parkinson disease

Several medical conditions have oral manifestations, which must be carefully considered when attempting to arrive at an accurate dental diagnosis. Many of the oral soft tissue changes that occur are more related to the medications used to treat the medical condition rather than to the condition itself. More common examples of medication side effects are stomatitis, xerostomia, petechiae, ecchymoses, lichenoid mucosal lesions, and bleeding of the oral soft tissues.

When developing a dental diagnosis, a clinician must also be aware that some medical conditions can have clinical presentations that mimic oral pathologic lesions. For example, tuberculosis involvement of the cervical and submandibular lymph nodes can lead to a misdiagnosis of lymph node enlargement secondary to an odontogenic infection. Lymphomas can involve these same lymph nodes. Immunocompromised patients and patients with uncontrolled diabetes mellitus respond poorly to dental treatment and may exhibit recurring abscesses in the oral cavity that must be differentiated from abscesses of dental origin. Patients with iron deficiency anemia, pernicious anemia, and leukemia frequently exhibit paresthesia of the oral soft tissues. This finding may complicate making a diagnosis when other dental pathosis is present in the same area of the oral cavity. Sickle cell anemia has the complicating factor of bone pain, which mimics odontogenic pain, and loss of trabecular bone pattern on radiographs, which can be confused with radiographic lesions of endodontic origin. Multiple myeloma can result in unexplained mobility of teeth. Radiation therapy to the head and neck region can result in increased sensitivity of the teeth and osteoradionecrosis. Trigeminal neuralgia, referred pain from cardiac angina, and multiple sclerosis can also mimic dental pain (see also Chapter 17 ). Acute maxillary sinusitis is a common condition that may create diagnostic confusion because it may mimic tooth pain in the maxillary posterior quadrant. In this situation the teeth in the quadrant may be extremely sensitive to cold and percussion, thus mimicking the signs and symptoms of pulpitis. This is certainly not a complete list of all the medical entities that can mimic dental disease, but it should alert the clinician that a medical problem could confuse and complicate the diagnosis of dental pathosis; this issue is discussed in more detail in subsequent chapters.

If, at the completion of a thorough dental examination, the subjective, objective, clinical testing and radiographic findings do not result in a diagnosis with an obvious dental origin, then the clinician must consider that an existing medical problem could be the true source of the pathosis. In such instances, a consultation with the patient’s physician is always appropriate.

Dental History

The chronology of events that lead up to the chief complaint is recorded as the dental history . This information will help guide the clinician as to which diagnostic tests are to be performed. The history should include any past and present symptoms, as well as any procedures or trauma that might have evoked the chief complaint. Proper documentation is imperative. It may be helpful to use a premade form to record the pertinent information obtained during the dental history interview and diagnostic examination. Often a SOAP format is used, with the history and findings documented under the categories of S ubjective, O bjective, A ppraisal, and P lan. There are also built-in features within some practice management software packages that allow digital entries into the patient’s electronic file for the diagnostic workup ( Figs. 1-3 and 1-4 ).

FIG. 1-3
When taking a dental history and performing a diagnostic examination, often a premade form can facilitate complete and accurate documentation.
(Courtesy Dr. Ravi Koka, San Francisco, CA.)

FIG. 1-4
Several practice management software packages have features for charting endodontic diagnoses using user-defined drop-down menus and areas for specific notations. Note that for legal purposes, it is desirable that all recorded documentation have the ability to be locked, or if any modifications are made after 24 hours, the transaction should be recorded with an automated time/date stamp. This is necessary so that the data cannot be fraudulently manipulated.
(Courtesy PBS Endo, Cedar Park, TX.)

History of Present Dental Problem

The dialogue between the patient and the clinician should encompass all of the details pertinent to the events that led to the chief complaint. The clinician should direct the conversation in a manner that produces a clear and concise narrative that chronologically depicts all of the necessary information about the patient’s symptoms and the development of these symptoms. To help elucidate this information, the patient is first instructed to fill out a dental history form as a part of the patient’s office registration. This information will help the clinician decide which approach to use when asking the patient questions. The interview first determines what is going on in an effort to determine why is it going on for the purpose of eventually determining what is necessary to resolve the chief complaint.

Dental History Interview

After starting the interview and determining the nature of the chief complaint, the clinician continues the conversation by documenting the sequence of events that initiated the request for an evaluation. The dental history is divided into five basic directions of questioning: localization, commencement, intensity, provocation and attenuation, and duration.

  • Localization. “Can you point to the offending tooth?” Often the patient can point to or tap the offending tooth. This is the most fortunate scenario for the clinician because it helps direct the interview toward the events that might have caused any particular pathosis in this tooth. In addition, localization allows subsequent diagnostic tests to focus more on this particular tooth. When the symptoms are not well localized, the diagnosis is a greater challenge.

  • Commencement. “When did the symptoms first occur?” A patient who is having symptoms often remembers when these symptoms started. Sometimes the patient will even remember the initiating event: it may have been spontaneous in nature; it may have begun after a dental visit for a restoration; trauma may be the etiology, biting on a hard object may have initially produced the symptoms, or the initiating event may have occurred concurrently with other symptoms (sinusitis, headache, chest pain, etc.). However, the clinician should resist the tendency to make a premature diagnosis based on these circumstances. The clinician should not simply assume “guilt by association” but instead should use this information to enhance the overall diagnostic process.

  • Intensity. “How intense is the pain?” It often helps to quantify how much pain the patient is actually having. The clinician might ask, “On a scale from 1 to 10, with 10 the most severe, how would you rate your symptoms?” Hypothetically, a patient could present with “an uncomfortable sensitivity to cold” or “an annoying pain when chewing” but might rate this “pain” only as a 2 or a 3. These symptoms certainly contrast with the type of symptoms that prevent a patient from sleeping at night. Often the intensity can be subjectively measured by what is necessary for the diminution of pain—for example, acetaminophen versus a narcotic pain reliever. This intensity level may affect the decision to treat or not to treat with endodontic therapy. Pain is now considered a standard vital sign, and documenting pain intensity (scale of 0 to 10) provides a baseline for comparison after treatment.

  • Provocation and attenuation. “What produces or reduces the symptoms?” Mastication and locally applied temperature changes account for the majority of initiating factors that cause dental pain. The patient may relate that drinking something cold causes the pain or possibly that chewing or biting is the only stimulus that “makes it hurt.” The patient might say that the pain is only reproduced on “release from biting.” On occasion, a patient may present to the dental office with a cold drink in hand and state that the symptoms can only be reduced by bathing the tooth in cold water. Nonprescription pain relievers may relieve some symptoms, whereas narcotic medication may be required to reduce others (see Chapter 4 for more information). Note that patients who are using narcotic as well as non-narcotic (e.g., ibuprofen) analgesics may respond differently to questions and diagnostic tests, thereby altering the validity of diagnostic results. Thus, it is important to know what drugs patients have taken in the previous 4 to 6 hours. These provoking and relieving factors may help the clinician to determine which diagnostic tests should be performed to establish a more objective diagnosis.

  • Duration. “Do the symptoms subside shortly, or do they linger after they are provoked?” The difference between a cold sensitivity that subsides in a few seconds and one that subsides in minutes may determine whether a clinician repairs a defective restoration or provides endodontic treatment. The duration of symptoms after a stimulating event should be recorded to establish how long the patient felt the sensation in terms of seconds or minutes. Clinicians often first test control teeth (possibly including a con­tralateral “normal” tooth) to define a “normal” response for the patient; thus, “lingering” pain is apparent when comparing the duration between the control teeth and the suspected tooth.

With the dental history interview complete, the clinician has a better understanding of the patient’s chief complaint and can concentrate on making an objective diagnostic evaluation, although the subjective (and artistic) phase of making a diagnosis is not yet complete and will continue after the more objective testing and scientific phase of the investigatory process.

Examination and Testing

Extraoral Examination

Basic diagnostic protocol suggests that a clinician observe patients as they enter the operatory. Signs of physical limitations may be present, as well as signs of facial asymmetry that result from facial swelling. Visual and palpation examinations of the face and neck are warranted to determine whether swelling is present. Many times a facial swelling can be determined only by palpation when a unilateral “lump or bump” is present. The presence of bilateral swellings may be a normal finding for any given patient; however, it may also be a sign of a systemic disease or the consequence of a developmental event. Palpation allows the clinician to determine whether the swelling is localized or diffuse, firm or fluctuant. These latter findings will play a significant role in determining the appropriate treatment.

Palpation of the cervical and submandibular lymph nodes is an integral part of the examination protocol. If the nodes are found to be firm and tender along with facial swelling and an elevated temperature, there is a high probability that an infection is present. The disease process has moved from a localized area immediately adjacent to the offending tooth to a more widespread systemic involvement.

Extraoral facial swelling of odontogenic origin typically is the result of endodontic etiology because diffuse facial swelling resulting from a periodontal abscess is rare. Swellings of nonodontogenic origin must always be considered in the differential diagnosis, especially if an obvious dental pathosis is not found. This situation is discussed in subsequent chapters.

A subtle visual change such as loss of definition of the nasolabial fold on one side of the nose may be the earliest sign of a canine space infection ( Fig. 1-5 ). Pulpal necrosis and periradicular disease associated with a maxillary canine should be suspected as the source of the problem. Extremely long maxillary central incisors may also be associated with a canine space infection, but most extraoral swellings associated with the maxillary centrals express themselves as a swelling of the upper lip and base of the nose.

FIG. 1-5
A, Canine space swelling of the left side of the face extending into and involving the left eye. B, Swelling of the upper lip and the loss of definition of the nasolabial fold on the patient’s left side, which indicates an early canine space infection.

If the buccal space becomes involved, the swelling will be extraoral in the area of the posterior cheek ( Fig. 1-6 ). These swellings are generally associated with infections originating from the buccal root apices of the maxillary premolar and molar teeth and the mandibular premolar ( Fig. 1-7 ) and first molar teeth. The mandibular second and third molars may also be involved, but infections associated with these two teeth are just as likely to exit to the lingual where other spaces would be involved. For infections associated with these teeth, the root apices of the maxillary teeth must lie superior to the attachment of the buccinator muscle to the maxilla, and the apices of the mandibular teeth must be inferior to the buccinator muscle attachment to the mandible.

FIG. 1-6
Buccal space swelling associated with an acute periradicular abscess from the mandibular left second molar.

FIG. 1-7
A, Buccal space swelling of the left side of the patient’s face. Note the asymmetry of the left side of the face. B, Intraoral view shows swelling present in the left posterior mucobuccal fold. C, This buccal space infection was associated with periradicular disease from the mandibular left second premolar. Note on the radiograph the periradicular radiolucency and large restoration associated with this tooth.

Extraoral swelling associated with mandibular incisors will generally exhibit itself in the submental ( Fig. 1-8 ) or submandibular space. Infections associated with any mandibular teeth, which exit the alveolar bone on the lingual and are inferior to the mylohyoid muscle attachment, will be noted as swelling in the submandibular space. Further discussions of fascial space infections may be found in Chapter 14 .

FIG. 1-8
Swelling of the submental space associated with periradicular disease from the mandibular incisors.

Sinus tracts of odontogenic origin may also open through the skin of the face ( Figs. 1-9 and 1-10 ). These openings in the skin will generally close once the offending tooth is treated and healing occurs. A scar is more likely to be visible on the skin surface in the area of the sinus tract stoma than on the oral mucosal tissues ( Fig. 1-10, C and D ). Many patients with extraoral sinus tracts give a history of being treated by general physicians, dermatologists, or plastic surgeons with systemic or topical antibiotics or surgical procedures in attempts to heal the extraoral stoma. In these particular cases, after multiple treatment failures, the patients may finally be referred to a dental clinician to determine whether there is a dental cause. Raising the awareness of physicians to such cases will aid in more accurate diagnosis and faster referral to the dentist or endodontist.

FIG. 1-9
A, Extraoral drainage associated with periradicular disease from the mandibular right canine. Note the parulis on the right anterior side of the face. B, Initial scar associated with the extraoral drainage incision after the parulis was drained and root canal therapy performed on the canine. C, Three-month follow-up shows healing of the incision area. Note the slight inversion of the scar tissue.

FIG. 1-10
A, Extraoral sinus tract opening onto the skin in the central chin area. B, Radiograph showing large radiolucency associated with the mandibular incisors. C, A culture is obtained from the drainage of the extraoral sinus tract. D, The healed opening of the extraoral sinus tract 1 month after root canal therapy was completed. Note the slight skin concavity in the area of the healed sinus tract.

Intraoral Examination

The intraoral examination may give the clinician insight as to which intraoral areas may need a more focused evaluation. Any abnormality should be carefully examined for either prevention or early treatment of associated pathosis. Swelling, localized lymphadenopathy, or a sinus tract should provoke a more detailed assessment of related and proximal intraoral structures.

Soft Tissue Examination

As with any dental examination, there should be a routine evaluation of the intraoral soft tissues. The gingiva and mucosa should be dried with either a low-pressure air syringe or a 2-by-2-inch gauze pad. By retracting the tongue and cheek, all of the soft tissue should be examined for abnormalities in color or texture. Any raised lesions or ulcerations should be documented and, when necessary, evaluated with a biopsy or referral.

Intraoral Swelling

Intraoral swellings should be visualized and palpated to determine whether they are diffuse or localized and whether they are firm or fluctuant. These swellings may be present in the attached gingiva, alveolar mucosa, mucobuccal fold, palate, or sublingual tissues. Other testing methods are required to determine whether the origin is endodontic, periodontic, or a combination of these two or whether it is of nonodontogenic origin.

Swelling in the anterior part of the palate ( Fig. 1-11 ) is most frequently associated with an infection present at the apex of the maxillary lateral incisor or the palatal root of the maxillary first premolar. More than 50% of the maxillary lateral incisor root apices deviate in the distal or palatal directions. A swelling in the posterior palate ( Fig. 1-12 ) is most likely associated with the palatal root of one of the maxillary molars.

FIG. 1-11
Fluctuant swelling in the anterior palate associated with periradicular disease from the palatal root of the maxillary first premolar.

FIG. 1-12
Fluctuant swelling in the posterior palate associated with periradicular disease from the palatal root of the maxillary first molar.

Intraoral swelling present in the mucobuccal fold ( Fig. 1-13 ) can result from an infection associated with the apex of the root of any maxillary tooth that exits the alveolar bone on the facial aspect and is inferior to the muscle attachment present in that area of the maxilla (see also Chapter 14 ). The same is true with the mandibular teeth if the root apices are superior to the level of the muscle attachments and the infection exits the bone on the facial. Intraoral swelling can also occur in the sublingual space if the infection from the root apex spreads to the lingual and exits the alveolar bone superior to the attachment for the mylohyoid muscle. The tongue will be elevated and the swelling will be bilateral because the sublingual space is contiguous with no midline separation. If the infection exits the alveolar bone to the lingual with mandibular molars and is inferior to the attachment of the mylohyoid muscle, the swelling will be noted in the submandibular space. Severe infections involving the maxillary and mandibular molars can extend into the parapharyngeal space, resulting in intraoral swelling of the tonsillar and pharyngeal areas. This can be life threatening if the patient’s airway becomes obstructed.

FIG. 1-13
Fluctuant swelling in the mucobuccal fold associated with periradicular disease from the maxillary central incisor.

Intraoral Sinus Tracts

On occasion, a chronic endodontic infection will drain through an intraoral communication to the gingival surface and is known as a sinus tract . This pathway, which is sometimes lined with epithelium, extends directly from the source of the infection to a surface opening, or stoma, on the attached gingival surface. As previously described, it can also extend extraorally. The term fistula is often inappropriately used to describe this type of drainage. The fistula, by definition, is actually an abnormal communication pathway between two internal organs or from one epithelium-lined surface to another epithelium-lined surface.

Histologic studies have found that most sinus tracts are not lined with epithelium throughout their entire length. One study found that only 1 out of the 10 sinus tracts examined were lined with epithelium, whereas the other nine specimens were lined with granulation tissue. Another study, with a larger sample size, found that two thirds of the specimens did not have epithelium extending beyond the level of the surface mucosa rete ridges. The remaining specimens had some epithelium that extended from the oral mucosa surface to the periradicular lesion. The presence or absence of an epithelial lining does not seem to prevent closure of the tract as long as the source of the problem is properly diagnosed and adequately treated and the endodontic lesion has healed. Failure of a sinus tract to heal after treatment will necessitate further diagnostic procedures to determine whether other sources of infection are present or whether a misdiagnosis occurred.

In general, a periapical infection that has an associated sinus tract is not painful, although often there is a history of varying magnitudes of discomfort before sinus tract development. Besides providing a conduit for the release of infectious exudate and the subsequent relief of pain, the sinus tract can also provide a useful aid in determining the source of a given infection. Sometimes objective evidence as to the origin of an odontogenic infection is lacking. The stoma of the sinus tract may be located directly adjacent to or at a distant site from the infection. Tracing the sinus tract will provide objectivity in diagnosing the location of the problematic tooth. To trace the sinus tract, a size #25 or #30 gutta-percha cone is threaded into the opening of the sinus tract. Although this may be slightly uncomfortable to the patient, the cone should be inserted until resistance is felt. After a periapical radiograph is exposed, the origin of the sinus tract is determined by following the path taken by the gutta-percha cone ( Fig. 1-14 ). This will direct the clinician to the tooth involved and, more specifically, to the root of the root of the tooth that is the source of the pathosis. Once the causative factors related to the formation of the sinus tract are removed, the stoma and the sinus tract will close within several days.

FIG. 1-14
A, To locate the source of an infection, the sinus tract can be traced by threading the stoma with a gutta-percha point. B, Radiograph of the area shows an old root canal in a maxillary second premolar and a questionable radiolucent area associated with the first premolar, with no clear indication of the etiology of the sinus tract. C, After tracing the sinus tract, the gutta-percha is seen to be directed to the source of pathosis, the apex of the maxillary first premolar.

The stomata of intraoral sinus tracts may open in the alveolar mucosa, in the attached gingiva, or through the furcation or gingival crevice. They may exit through either the facial or the lingual tissues depending on the proximity of the root apices to the cortical bone. If the opening is in the gingival crevice, it is normally present as a narrow defect in one or two isolated areas along the root surface. When a narrow defect is present, the differential diagnosis must include the opening of a periradicular endodontic lesion, a vertical root fracture, or the presence of a developmental groove on the root surface. This type of sinus tract can be differentiated from a primary periodontal lesion because the latter generally presents as a pocket with a broad coronal opening and more generalized alveolar bone loss around the root. Other pulp testing methods may assist in verifying the source of infection.


In the course of the soft tissue examination, the alveolar hard tissues should also be palpated. Emphasis should be placed on detecting any soft tissue swelling or bony expansion, especially noting how it compares with and relates to the adjacent and contralateral tissues. In addition to objective findings, the clinician should question the patient about any areas that feel unusually sensitive during this palpation part of the examination.

A palpation test is performed by applying firm digital pressure to the mucosa covering the roots and apices. The index finger is used to press the mucosa against the underlying cortical bone. This will detect the presence of periradicular abnormalities or specific areas that produce painful response to digital pressure. A positive response to palpation may indicate an active periradicular inflammatory process. This test does not indicate, however, whether the inflammatory process is of endodontic or periodontal origin.


Referring back to the patient’s chief complaint may indicate the importance of percussion testing for this particular case. If the patient is experiencing acute sensitivity or pain on mastication, this response can typically be duplicated by individually percussing the teeth, which often isolates the symptoms to a particular tooth. Pain to percussion does not indicate that the tooth is vital or nonvital but is rather an indication of inflammation in the periodontal ligament (i.e., symptomatic apical periodontitis). This inflammation may be secondary to physical trauma, occlusal prematurities, periodontal disease, or the extension of pulpal disease into the periodontal ligament space. The indication of where the pain originates is interpreted by the mesencephalic nucleus, receiving its information from proprioceptive nerve receptors. Although subject to debate, the general consensus is that there are relatively few proprioceptors in the dental pulp; however, they are prevalent in the periodontal ligament spaces. This is why it may be difficult for the patient to discriminate the location of dental pain in the earlier stages of pathosis, when only the C fibers are stimulated. Once the disease state extends into the periodontal ligament space, the pain may become more localized for the patient; therefore, the affected tooth will be more identifiable with percussion and mastication testing.

Before percussing any teeth, the clinician should tell the patient what will transpire during this test. Because the presence of acute symptoms may create anxiety and possibly alter the patient’s response, properly preparing the patient will lead to more accurate results. The contralateral tooth should first be tested as a control, as should several adjacent teeth that are certain to respond normally. The clinician should advise the patient that the sensation from this tooth is normal and ask to be advised of any tenderness or pain from subsequent teeth.

Percussion is performed by tapping on the incisal or occlusal surfaces of the teeth either with the finger or with a blunt instrument. The testing should initially be done gently, with light pressure being applied digitally with a gloved finger tapping. If the patient cannot detect significant difference between any of the teeth, the test should be repeated using the blunt end of an instrument, like the back end of a mirror handle ( Fig. 1-15 ). The tooth crown is tapped vertically and horizontally. The tooth should first be percussed occlusally, and if the patient discerns no difference, the test should be repeated, percussing the buccal and lingual aspects of the teeth. For any heightened responses, the test should be repeated as necessary to determine that it is accurate and reproducible, and the information should be documented.

FIG. 1-15
Percussion testing of a tooth, using the back end of a mirror handle.

Although this test does not disclose the condition of the pulp, it indicates the presence of a periradicular inflammation. An abnormal positive response indicates inflammation of the periodontal ligament that may be of either pulpal or periodontal origin. The sensitivity of the proprioceptive fibers in an inflamed periodontal ligament will help identify the location of the pain. This test should be done gently, especially in highly sensitive teeth. It should be repeated several times and compared with control teeth.


Like percussion testing, an increase in tooth mobility is not an indication of pulp vitality. It is merely an indication of a compromised periodontal attachment apparatus. This compromise could be the result of acute or chronic physical trauma, occlusal trauma, parafunctional habits, periodontal disease, root fractures, rapid orthodontic movement, or the extension of pulpal disease, specifically an infection, into the periodontal ligament space. Tooth mobility is directly proportional to the integrity of the attachment apparatus or to the extent of inflammation in the periodontal ligament. Often the mobility reverses to normal after the initiating factors are repaired or eliminated. Because determining mobility by simple finger pressure can be visually subjective, the back ends of two mirror handles should be used, one on the buccal aspect and one on the lingual aspect of the tooth ( Fig. 1-16 ). Pressure is applied in a facial-lingual direction as well as in a vertical direction and the tooth mobility is scored ( Box 1-2 ). Any mobility that exceeds +1 should be considered abnormal. However, the teeth should be evaluated on the basis of how mobile they are relative to the adjacent and contralateral teeth.

FIG. 1-16
Mobility testing of a tooth, using the back ends of two mirror handles.

Box 1-2
Recording Tooth Mobility

  • +1 mobility: The first distinguishable sign of movement greater than normal

  • +2 mobility: Horizontal tooth movement no greater than 1  mm

  • +3 mobility: Horizontal tooth movement greater than 1  mm, with or without the visualization of rotation or vertical depressability

Periodontal Examination

Periodontal probing is an important part of any intraoral diagnosis. The measurement of periodontal pocket depth is an indication of the depth of the gingival sulcus, which corresponds to the distance between the height of the free gingival margin and the height of the attachment apparatus below. Using a calibrated periodontal probe, the clinician should record the periodontal pocket depths on the mesial, middle, and distal aspects of both the buccal and lingual sides of the tooth, noting the depths in millimeters. The periodontal probe is “stepped” around the long axis of the tooth, progressing in 1-mm increments. Periodontal bone loss that is wide, as determined by a wide span of deep periodontal probings, is generally considered to be of periodontal origin and is typically more generalized in other areas of the mouth. However, isolated areas of vertical bone loss may be of an endodontic origin, specifically from a nonvital tooth whose infection has extended from the periapex to the gingival sulcus. Again, proper pulp testing is imperative, not just for the determination of a diagnosis but also for the development of an accurate prognosis assessment. For example, a periodontal pocket of endodontic origin may resolve after endodontic treatment, but if the tooth was originally vital with an associated deep periodontal pocket, endodontic treatment will not improve the periodontal condition. In addition, as discussed in Chapter 21 , a vertical root fracture may often cause a localized narrow periodontal pocket that extends deep down the root surface. Characteristically, the adjacent periodontium is usually within normal limits.

Furcation bone loss can be secondary to periodontal or pulpal disease. The amount of furcation bone loss, as observed both clinically and radiographically, should be documented ( Box 1-3 ). Results of pulp tests (described later) will aid in diagnosis.

Box 1-3
Recording Furcation Defects

  • Class I furcation defect: The furcation can be probed but not to a significant depth.

  • Class II furcation defect: The furcation can be entered into but cannot be probed completely through to the opposite side.

  • Class III furcation defect: The furcation can be probed completely through to the opposite side.

Pulp Tests

Pulp testing involves attempting to make a determination of the responsiveness of pulpal sensory neurons. The tests involve thermal or electrical stimulation of a tooth in order to obtain a subjective response from the patient (i.e., to determine whether the pulpal nerves are functional), or the tests may involve a more objective approach using devices that detect the integrity of the pulpal vasculature. Unfortunately, the quantitative evaluation of the status of pulp tissue can only be determined histologically, as it has been shown that there is not necessarily a good correlation between the objective clinical signs and symptoms and the pulpal histology.


Various methods and materials have been used to test the pulp’s response to thermal stimuli. The baseline or normal response to either cold or hot is a patient’s report that a sensation is felt but disappears immediately upon removal of the thermal stimulus. Abnormal responses include a lack of response to the stimulus, a lingering or intensification of a painful sensation after the stimulus is removed, or an immediate, excruciatingly painful sensation as soon as the stimulus is placed on the tooth.

Cold testing is the primary pulp testing method used by many clinicians today. It is especially useful for patients presenting with porcelain jacket crowns or porcelain-fused-to-metal crowns where no natural tooth surface (or much metal) is accessible. If a clinician chooses to perform this test with sticks of ice, then the use of a rubber dam is recommended, because melting ice will run onto adjacent teeth and gingiva, yielding potentially false-positive responses.

Frozen carbon dioxide (CO 2 ), also known as dry ice or carbon dioxide snow , or CO 2 stick , has been found to be reliable in eliciting a positive response if vital pulp tissue is present in the tooth. One study found that vital teeth would respond to both frozen CO 2 and skin refrigerant, with skin refrigerant producing a slightly quicker response. Frozen carbon dioxide has also been found to be effective in evaluating the pulpal response in teeth with full coverage crowns for which other tests such as electric pulp testing is not possible. For testing purposes, a solid stick of CO 2 is prepared by delivering CO 2 gas into a specially designed plastic cylinder ( Fig. 1-17 ). The resulting CO 2 stick is applied to the facial surface of either the natural tooth structure or crown. Several teeth can be tested with a single CO 2 stick. The teeth should be isolated and the oral soft tissues should be protected with a 2-by-2-inch gauze or cotton roll so the frozen CO 2 will not come into contact with these structures. Because of the extremely cold temperature of the frozen CO 2 (−69°F to −119°F; −56°C to −98°C), burns of the soft tissues can occur. It has been demonstrated on extracted teeth that frozen CO 2 application has resulted in a significantly greater intrapulpal temperature decrease than either skin refrigerant or ice. Also, it appears that the application of CO 2 to teeth does not result in any irreversible damage to the pulp tissues or cause any significant enamel crazing.

FIG. 1-17
A, Carbon dioxide tank with apparatus attached to form solid CO 2 stick/pencil. B, CO 2 gas being transformed into a solid stick/pencil. C, CO 2 stick/pencil extruded from end of a plastic carrier and ready for use.

The most popular method of performing cold testing is with a refrigerant spray. It is readily available, easy to use, and provides test results that are reproducible, reliable, and equivalent to that of frozen CO 2 . One of the current products contains 1,1,1,2-tetrafluoroethane, which has zero ozone depletion potential and is environmentally safe. It has a temperature of −26.2°C. The spray is most effective for testing purposes when it is applied to the tooth on a large #2 cotton pellet ( Fig. 1-18 ). In one study, a significantly lower intrapulpal temperature was achieved when a #2 cotton pellet was dipped or sprayed with the refrigerant compared with the result when a small #4 cotton pellet or cotton applicator was used. The sprayed cotton pellet should be applied to the midfacial area of the tooth or crown. As with any other pulp testing method, adjacent or contralateral “normal” teeth should also be tested to establish a baseline response. It appears that frozen CO 2 and refrigerant spray are superior to other cold testing methods and equivalent or superior to the electric pulp tester for assessing pulp vitality. However, one study found that periodontal attachment loss and gingival recession may influence the reported pain response with cold stimuli.

FIG. 1-18
A, Refrigerant spray container. B, A large cotton pellet made of a cotton roll or a ready-made size #2 (large) cotton pellet can be used to apply the refrigerant spray to the tooth surface. The small #4 cotton pellet does not provide as much surface area as the #2 cotton pellet, and therefore should not be used to deliver the refrigerant to the tooth surface. C, A large cotton pellet sprayed with the refrigerant and ready to be applied to the tooth surface.
( A, Courtesy Coltène/Whaledent, Cuyahoga Falls, OH.)

To be most reliable, cold testing should be used in conjunction with an electric pulp tester (described later in this chapter) so that the results from one test will verify the findings of the other test. If a mature, nontraumatized tooth does not respond to both cold testing and electric pulp testing, then the pulp should be considered necrotic. However, a multirooted tooth, with at least one root containing vital pulp tissue, may respond to a cold test and electric pulp test even if one or more of the roots contain necrotic pulp tissue.

Another thermal testing method involves the use of heat. Heat testing is most useful when a patient’s chief complaint is intense dental pain on contact with any hot liquid or food. When a patient is unable to identify which tooth is sensitive, a heat test is appropriate. Starting with the most posterior tooth in that area of the mouth, each tooth is individually isolated with a rubber dam. An irrigating syringe is filled with a liquid (most commonly plain water) that has a temperature similar to that which would cause the painful sensation. The liquid is then expressed from the syringe onto the isolated tooth to determine whether the response is normal or abnormal. The clinician moves forward in the quadrant, isolating each individual tooth until the offending tooth is located. That tooth will exhibit an immediate, intense painful response to the heat. With heat testing, a delayed response may occur, so waiting 10 seconds between each heat test will allow sufficient time for the onset of symptoms. This method can also be used to apply cold water to the entire crown for cases in which cold is the precipitating stimulus.

Another method for heat testing is to apply heated gutta-percha or compound stick to the surface of the tooth. If this method is used, a light layer of lubricant should be placed onto the tooth surface before applying the heated material to prevent the hot gutta-percha or compound from adhering to the dry tooth surface. Heat can also be generated by the friction created when a dry rubber-polishing wheel is run at a high speed against the dry surface of a tooth. However, this latter method is seldom used today and is not recommended. Another approach is the use of electronic heat-testing instruments.

If the heat test confirms the results of other pulp testing procedures, emergency care can then be provided. Often a tooth that is sensitive to heat may also be responsible for some spontaneous pain. The patient may present with cold liquids in hand just to minimize the pain ( Fig. 1-19 ). In such cases, the application of cold to a specific tooth may eliminate the pain and greatly assist in the diagnosis. Typically, a tooth that responds to heat and then is relieved by cold is found to be necrotic.

Apr 18, 2020 | Posted by in General Dentistry | Comments Off on Diagnosis
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