It is an acute exacerbation of a previously existing chronic lesion. The main objective of diagnosis is to identify the cause of the patient’s complaints or because of some abnormal findings during routine clinical exam, which in turn aids the clinician in deciding the ideal treatment required for that particular patient. Previously Initiated Therapy – A clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy (e.g. Toronto, Ontario M5G 1G6. Clinically, this lesion is asymptomatic and is detected radiographically by a periradicular radiolucency. It is a result of an increase in the virulence of the bacteria or decrease in the patient’s resistance. Chronic apical abscess – An inflammatory reaction to pulpal infection and necrosis characterized by gradual onset, little or no discomfort and the intermittent discharge of pus through an associated sinus tract. The medical history may provide relevant information related to the health status of the patient, and will offer the dentist knowledge of preexisting medical conditions and current medications that may necessitate altering the manner in which dental care is provided. A complete endodontic diagnosis is made up of two parts: (1) Pulpal diagnosis and (2) Periapical diagnosis. June 1: Endodontics, Periodontology, Prosthodontics. McGill University. Usually, Acute Periradicular Periodontitis does not present any radiographic changes since they occur rapidly. In a “true cyst” lumen does not communicate with the apical foramen. Dr. Fox graduated from the University of Toronto, Faculty of Dentistry, in 2006. Vaughan, Ontario, Canada. A common finding with a fractured cusp or cracked tooth is the presence of pain on the release of biting pressure. In 2009, Dr. Margel obtained his dental degree from The University of Pennsylvania. Oral Surgery Referral Form. In an effort to simplify and unify the endodontic diagnostic terminology, the ABE has recently published a list of pulpal and periapical diagnostic terminology. Seltzer and Bender‘s Dental Pulp. The patient is instructed to hold the tester probe and to remove his/her finger(s) once a tingling or warming sensation is felt. Toronto, Ontario, Canada. Differential diagnosis should be assessed if lack of response is found with recently traumatized teeth. Cold test can be conducted by using frozen carbon dioxide delivered using a specially designed plastic cylinder. Graduate Prosthodontics Clinic Referral . These methods are not commonly used in clinical settings. of: Color atlas and text of endodontics. Endodontics – Assistant Professor . Dr. Fox has published original research papers in the Journal of Endodontics and Ontario Dentist. Sep 2015 – Present 5 years 2 months. The M.Sc. This objective test works by transmitting two wavelengths of light, red and infrared. The infection may spread along the facial planes to form a cellulitis, and systemic symptoms such as fever, malaise may be present in these patients. It is important to realize that the problems must not be dealt with in isolation and any treatment plan should take the entire mouth and the patient’s general medical condition and attitude into consideration. 28. Non odontogenic swelling also have to be considered, especially if no obvious dental etiology is found. Schulich School of Medicine & Dentistry . As a general rule, the adjacent teeth must be tested to compare the findings. The threshold of stimulation for A delta nerve fibers is lowered. Calvin does research in Molecular Biology, Microbiology and Restorative Dentistry and Endodontics. Chronic Suppurative Periodontitis are apical lesions that have established drainage by breaking through the cortical plate of the bone and overlying periodontal tissues. The tooth in this case may be elevated out of its socket because of the buildup of fluid pressure in the PDL. Dr. Da Costa received his Doctor of Dental Surgery degree in 1991, from the University of Toronto. The University and its divisions may use the postal mail system and/or electronic message services (e.g., electronic mail and other computer-based on-line correspondence systems) as mechanisms for delivering official correspondence to … To achieve this objective it is recommended to record the patient’s chief complaint, ask about the symptoms and history of the complaint (subjective findings), perform objective clinical tests coupled with appropriate investigations and correlate the objective findings with the subjective information. Dr. Nahmias resides in Toronto, Ontario with his wife and five children and maintains a private specialty practice in Oakville, Ontario × DR. JIM LAI D.M.D., M.Sc., (Perio), Ed.D., F.R.C.D. Toronto, Ontario M5G 1G6. imprint. 1550091883 (hbk.) endodontics . Trowbridge HO, Kim S. Pulp development structure and function. It requires a surgical root canal treatment. 416-864-8100. The teeth involved in the test should be isolated individually. Sep 2015 – Present 5 years 2 months. His passion is ensuring patients receive the utmost professional endodontic treatment available and helping to plan, treat and manage patients’ oral health. The dental pulp. It is recommended that the tooth to be tested is isolated and dried, and tested at least twice. Edinburgh ; New York : Mosby/Elsevier, [2014] isbn. If not, complications arising during endodontic treatment may have legal consequences. St Louis: CV Mosby,337-62, 1994. Cracks in teeth may also be detected by a wedging and staining procedure. To perform the electric test, the probe of the electric pulp tester should be placed in contact with the natural tooth and the patient may be required to place a finger(s) on the tester probe to complete the electrical circuit. Dr Fox practiced as a general dentist for 9 years, prior to returning to the University of Toronto in 2015, where he completed his Masters in Endodontics in 2018. J Endodon, 12, 1986. For the cavity test, a small class 1 cavity preparation is made on the occlusal surface of the crown with a high speed handpiece and round burs #1 or # 2 with proper air and water coolant. Home > Dental Professionals and Students > Accredited Programs > University of Toronto University of Toronto Dental Education Program Contact Information The sprayed cotton pellet is applied to the mid buccal surface of the crown. Toronto, Ontario M5G 1G6. 2013 – Present 7 years. Doctor of Dental Surgery. Goldman Melvin Goldman, Arthur H. Pearson, Nicholas Darzenta D. Endodontic Success—Who’s Reading The Radiograph? Endodontics covers the: morphology, physiology and pathology of the dental pulp and periradicular tissues; basic clinical sciences, ... University of Toronto - Faculty of Dentistry. A percussion test may be used to duplicate the symptoms when the patient refers pain upon mastication. Radiological diagnosis of the affected tooth is mandatory prior to any root canal treatment. Treatment Outcome in Endodontics - The Toronto Study. PMNs (polymorphonucear leukocytes) are involved and they cause exacerbation of inflammation. 3) University of Toronto Qualifying Program is offered at the following Canadian dental school(s): 1) University of Toronto Irreversible pulpitis – A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed pulp is incapable of healing. The soft tissues overlying the root apices of suspect and control teeth are palpated to locate tender areas. The most common method to perform a cold test is with refrigerant spray, which provides reproducible, reliable and equivalent result as with the CO2 stick. During testing, the sensor should conform well with the anatomy of the tooth so that all emitted light is received by the detector. It is important to remember that the presence of extra roots or canals in all teeth is much more common than was previously believed. From the *Discipline of Endodontics and †Discipline of Prosthodontics, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada. Endodontics [electronic resource] / edited by Kishor Gulabivala, BDS, MSc, FDS RCS (Edin), PhD, FHEA, Yuan-Ling Ng, BDS, MSc, MRD RCS (Eng), PhD, FHEA. To achieve this objective it is recommended to record the patient’s chief complaint, ask about the sympto… During this test, the clinician should first anesthetize selectively the maxilla by using intraligamentary anesthesia, starting with the most posterior tooth. Numerical readings on the pulp tester have significance only if the number differs significantly from the readings obtained from a control tooth tested on the same patient with the electrode positioned at a similar area on both teeth. 101 Elm Street. University of Toronto - Faculty of Dentistry, University of Toronto Faculty of Dentistry Information and Instructional Technology Services, 2.B Take a detailed medical and dental history, 2. University of Toronto - Faculty of Dentistry. September 1: Dental Anaesthesia, Oral Medicine, Oral Medicine and Pathology, ... University of Toronto students applying to the dentistry program do not need to send in their official University of Toronto transcripts. Full Member, School of Graduate Studies, University of Toronto. Walton R, Torabinejad M, Principles and Practice of Endodontics. A total of 106 teeth were treated. The probe must be coated with a petroleum based conductive medium (example: tooth paste) before touching the tooth surface. It indicates that the health of the periodontal tissues is compromised. Welcome to the Graduate Endodontics Program at the University of Toronto's Faculty of Dentistry. Radiological interpretations are an important step in clinical examination. A response to electric pulp test only indicates that some viable nerve fibers are present in the pulp and are capable of responding to mild electric current. Seltzer S. Endodontology. Endodontics: Principles And Practice Edition 4, Illustrated Elsevier Health Sciences, 2009. Amir Azarpazhooh victoriahetherington Tue, 07/12/2016 - 14:35. This may lead to a false-positive response from teeth with necrotic pulp tissue. Professor and Chairman Department of Endodontics Institute of Clinical Dentistry Faculty of Dentistry University of Oslo Oslo, Norway. Dr. Sophia Lalani received her D.M.D from Boston University Henry M. Goldman School of Dental Medicine in 2009 and continued on at the same institution to complete a 2-year residency in the post-graduate Endodontic program. The patients also present spontaneous dull, aching pain caused by the stimulation of unmyelinated C fibers in the pulp. In Cohen S, Burns RC. University of Toronto, Graduate Endodontics Program 124 Edward Street Toronto, M5G 1G6 . A thermal test commonly employs either hot or cold approaches. Vital pulp testing will be helpful in confirming the origin. The clinician has to record the readings from the pulp tester. Want to study abroad in Canada? 5th ed., Saunders, 2009. This Masters programme is designed for dental graduates who wish to develop clinical skills in endodontics. Acute periradicular periodontitis indicates inflammation in the PDL (periodontal ligament) caused by tissue damage and the extension of pulpal pathosis or occlusal trauma. This is usually indicated by localized inflammation of the pulp with localized increase in the intrapulpal pressure. Seltzer S, Bender IB. Most orofacial pain is of pulpal or periradicular origin and the pain to thermal stimulus is often an indication of an endodontic problem. Dentistry (with Specialty Training) Home; Programs; Dentistry (with Specialty Training) Program Overview. 3rd ed. She is a Fellow of the Royal College of Dentists of Canada in the specialty of endodontics. Certain medical conditions may have oral manifestations or mimic dental pathosis. Pulp testing is utilized to determine the status of the sensory neurons present in the pulp and the integrity of the pulpal vasculature. This information is critical because it will guide the dentist as to which tests/investigation is to be performed. Bettina Basrani. A cutaneous sinus tract of dental origin is relatively uncommon and may be misdiagnosed easily. This is usually associated with a localized area of necrosis in the pulp, which cannot be repaired or confined. Pathologic conditions such as neuralgia, multiple sclerosis, myocardial ischemia and psychiatric disorders may also produce symptoms that are confused with tooth pain. Book Online. The M.Sc. Microscopically, this granulomatous tissue is comprised of lymphocytes, plasma cells, and macrophages surrounded by a relatively uninflamed fibrous capsule made up of collagen, fibroblasts, and capillary buds. Toronto ON M5G 1E2 Canada. Pulp necrosis – A clinical diagnostic category indicating death of the dental pulp. Quintessence Int., 2002. On the contrary, absence of sensation indicates a necrotic pulp. 2nd ed. A clinical examination of the patient is carried out after the case history has been completed. Philadelphia: JB Lippincott, 1984. Click here to load MARC record Z Fuss, H Trowbridge, IB Bender, B Rickoff and S Sorin, Assessment of reliability of electrical and thermal pulp testing agents. The presence of metallic restorations interferes with measurements by Pulse Oximetry. Faculty of Dentistry at the University of Toronto. As long as the irritants keep emanating from the root canal system, the soft tissue lesion will keep expanding at the expense of the surrounding bone. The patient is asked to apply biting pressure with the opposing teeth to the flat surface on the opposite side of the device. Periradicular cyst development occurs if the inflammation of the periradicular tissue stimulates the epithelial rests of Malassez to begin dividing. Gevik Malkhassian. Pulse Oximetry is designed to measure the oxygen saturation level in the blood and the pulse rate. Studies have demonstrated a lack of good correlation between the objective clinical signs/symptoms and histo-pathological status of the pulp. The increase in the mobility of a tooth is not necessarily an indication of pulpal infection. From the *Discipline of Endodontics and †Discipline of Prosthodontics, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada. A root canal should be readily discernible. Licensed for access by U. of T. users. Hours & Locations; Navigation Endodontics program is designed to provide students with opportunities to acquire excellent clinical skills and comprehension of the underlying ... (3.70 GPA) for the Ph.D. program from the University of Toronto or its equivalent from another recognized university. University of Toronto. In the case of an abnormal response, the patient may not experience any sensation, or may experience lingering or intensification of the sensation or an immediate, excruciatingly painful sensation after the thermal stimulus is applied on the tooth. Tracking a sinus tract will provide an important clue for the proper diagnosis. Undergraduate Endodontics Referral Form . This test is very useful when testing teeth that have suffered traumatic injuries. Dr Fox practiced as a general dentist for 9 years, prior to returning to the University of Toronto in 2015, where he completed his Masters in Endodontics in 2018. Toronto Oral Pathology Services Biopsy Form . Dr. Dana also completed his Doctor of Dental Surgery (DDS) degree at the University of Toronto in 2013 and also enrolled in the Implantology mini-residency program in the Oral Reconstruction Clinic at the University of Toronto. Address requests for reprints to Shimon Friedman, DMD, Professor and Head, Discipline of Endodontics, Faculty of Dentistry, University of Toronto, 124 Edward St, Toronto, Ontario, M5G 1G6, Canada. The clinician should monitor presence of pain upon closing or upon releasing the occlusal pressure. University of Toronto - Faculty of Dentistry. From understanding the underlying biology, to diagnosis and prevention, including topics such as epidemiology, treatment outcomes, and the optimization of root canal procedures. Seltzer S, Bender IB 4th ed. This information may lead directly to the problem, or in some cases will offer relevant clues that will facilitate one to arrive at an accurate diagnosis after the completion of the examination. Graduate Periodontal Clinic Referral Form. In these cases, a “sinus tract” is present, and the patient is usually asymptomatic. This test is mainly used to determine the presence of cracks or vertical crown fractures. She was awarded for her presentation of this research by the American Association of Endodontics. Toronto, Ontario M5G 1G6. Aldo DEL CARPIO-PEROCHENA of University of Toronto, Toronto (U of T) | Read 28 publications | Contact Aldo DEL CARPIO-PEROCHENA Pathways of the pulp. Clinical professor for Graduate Endodontics. Diagnosis is the art and science of identifying a disease or distinguishing one disease from another, by carefully considering the history, symptoms and signs. Network. On the other hand, if the source of cold is applied very close to the soft tissues, the patient may experience pain or sensitivity that is not related to the tooth being tested, but associated to these soft tissues. About. False negative responses to cold may be found in cases of calcified tooth tissue which is a more common finding in elderly patients. Endodontic therapy is advised in these cases. Normal pulp – A clinical diagnostic category in which the pulp is symptom free and normally responsive to vitality testing. Search by ISBN or Product Name. London, CANADA . The response of the pulp to the electric pulp testing does not reflect the histologic health or disease status of the pulp. Reversible pulpitis – A clinical diagnosis based upon subjective and objective findings indicating that the inflammation should resolve and the pulp return to normal. You will hone your clinical skills in all aspects of endodontic treatment in this program and contribute to critical bodies of knowledge through your own research. The alcohol washes away the dye on the surface, but the dye within the fracture line remains and becomes apparent. or Prophylactic antibiotic coverage has been recommended for certain medical conditions, depending upon the complexity of the procedure and the degree of bacteraemia expected, but the type of antibiotic and the dosage are under continual review and dental practitioners should be aware of current opinion. The testing for percussion sensitivity should initially be carried out gently, with light occlusal pressure, applied digitally with a finger. If a mature untraumatized tooth does not respond to both tests it must be considered necrotic. The periodontium, jaws, sinuses, ears, temporomandibular joints, masticatory musculature, nose, eyes, blood vessels and other structures may induce pain that mimics pulpal pain. Toronto, Ontario, Canada. The small cupped area on the tooth slooth is placed in contact with the cusp to be tested. The clinician must be ready to notice any signs of physical limitations, as well as facial asymmetry from the very first time the patient enters the office. Clinical Endodontics by Leif Tronstad The third edition of Clinical Endodontics retains the successful format and practical scope of previous editions. This implies a breakdown of the host immune system, which usually contains the microbes inside the root canal system. Pavel Cherkas. Dr. Aaron Fox graduated from the University of Toronto in 2006, where he completed his DDS. The associated inflammation frequently spreads throughout the pulp. The University of Western Ontario (Western University) is an internationally renowned research-intensive university that is ranked among the topten in Canada, and prides itself in the “student - experience” of its educational programs. Calvin Torneck currently works at the Dentistry, Discipline of Endodontics, University of Toronto. Caries or irritants should be removed and a sedative dressing should be placed. Overview. For both hot and cold tests it is recommended to isolate the tooth with a rubber dam. 6th ed. Listening carefully to the patient’s description of his/her symptoms can provide invaluable information. However, all chronic draining sinus tracts of the face or neck should signal the need for thorough dental evaluation. In these situations, the pulp usually has preexisting chronic pulpitis, which decreases the ability of pulp to respond favorably to vital pulp therapy. Endodontics. Cone bean CT, other scans: Cone beam computed tomography (CBCT), ultrasound, and other emerging technologies seem to be very promising tools for more accurate diagnosis of changes in the root supporting structures. The chief complaint is the reason(s) that the patient provides for consulting the dentist. University of Western Ontario . Dr. Rastegar joined the dental community in London Ontario providing care in a busy general dental practice until 1993, when he further pursued post-doctorial training in Endodontics at the University of Michigan. Computed tomography uses a fan-shaped beam and multiple exposures around an object to reveal the internal architecture of this object. Normal apical tissues – Teeth with normal periradicular tissues that will not be abnormally sensitive to percussion or palpation testing. Weine F, Endodontic Therapy. Visiting Professor of Endodontics, King Juan Carlos University at Madrid, Spain IITS secondary menu. The pulp tests are essential and the findings must be correlated with other diagnostic information in order to differentiate inflammation of pulpal origin from occlusal trauma. IITS Home; Faculty of Dentistry; Alumni; Continuing Education; Main navigation. An assessment of the patient’s general dental status is usually made by noting in particular the following aspects: standard of oral hygiene, amount and quality of restorative work, prevalence of caries, missing and unopposed teeth, general periodontal condition, presence of soft or hard swellings, and presence of any sinus tracts, discoloured teeth, tooth wear and facets. Authored by: Dr. Andres Plazas-Garzon. The University of Toronto Faculty of Dentistry has involved Dr. Nahmias in teaching their postgraduate level students in endodontics. Dr. Markovic teaches as a clinical instructor at University of Toronto. The University of Pennsylvania School of Dental Medicine has the unique honor of being the birthplace of modern endodontics with Dr. Louis Grossman, the father of modern endodontics, having established the Penn Dental Medicine endodontic program. Specific information closely related with the chief complaint must be recorded as the dental history. A necrotic tooth does not cause radiographic changes at the apex until the periapical pathosis has destroyed bony trabeculae at their junction with the cortical plate. As part of her training to become an Endodontist, Dr. Phee worked as a clinical instructor at the University of Toronto and she published her Master's Thesis in the Journal of Endodontics titled "Efficacy of Bacteriophage Reduction on Pseudomonas aeruginosa Biofilms". Eds. Different approaches have been used for the bite test. Label Label Label. The patient is not anesthetized, and the patient is asked to respond if any painful sensation is felt. Diagnosis is the art and science of identifying a disease or distinguishing one disease from another, by carefully considering the history, symptoms and signs. 43.6556, -79.3868. This also applies if the patient is on medication, such as corticosteroids or an anticoagulant. Pain to percussion is not an indication of tooth vitality, but will indicate the existence of inflammation in the periodontal ligament. Discipline of Endodontics University of Toronto Toronto, Ontario, Canada Yosef Nahmias, DDS, MSc Private Practice Oakville, Ontario, Canada Le O’Leary, DDS Private Practice Plano, TX, USA Dag Ørstavik, dr. odont. + 1 computer optical disc. The pulp is non-responsive to vitality testing. Pathways of the pulp. It is one of the most important responsibilities of the clinician to document a proper medical history of the patient. If there is any doubt about the state of a patient’s health, his/her general medical practitioner should be consulted before any endodontic treatment is commenced. Asymptomatic apical periodontitis – Inflammation and destruction of apical periodontium that is of pulpal origin, appears as an apical radiolucent area and does not produce clinical symptoms. 5761361 Radiology is an indispensable tool in the clinical practice of endodontics because most structures harboring disease are not visible to the naked eye. 1 Discipline of Endodontics, Faculty of Dentistry, University of Toronto, Ontario, Canada. Endodontics [electronic resource] / edited by Kishor Gulabivala, BDS, MSc, FDS RCS (Edin), PhD, FHEA, ... University of Toronto Libraries 130 St. George St.,Toronto, … contents note. The book opens with an overview of the biology of the endodontium and the apical periodontium. Rev. The stoma of the intraoral sinus tract may open in the alveolar mucosa, attached gingiva, or on the furcation or gingival crevice. Symptomatic apical periodontitis – Inflammation, usually of the apical periodontium, producing clinical symptoms including painful response to biting and percussion. Overview of graduate studies with specialty training, Application form on the School of Graduate Studies website, Oral and Maxillofacial Pathology and Oral Medicine, University of Toronto - Faculty of Dentistry, MSc or PhD program with specialist clinical training, application process for Graduate studies without clinical training, Number of spaces available across MSc and PhD, morphology, physiology and pathology of the dental pulp and periradicular tissues, basic clinical sciences, including biology of the normal pulp. Outcome 4-6 years after retreatment was assessed for Phases 3 and 4 of the Toronto Study. Clinically, the patient is usually asymptomatic, while radiographical evaluation of the periradicular area shows increased bone density and trabeculation. Acute apical abscess – An inflammatory reaction to pulpal infection and necrosis characterized by rapid onset, spontaneous pain, tenderness of the tooth to pressure, pus formation and swelling of associated tissues. The lamina dura surrounding the root is intact and the periodontal ligament space is uniform. Department of Dentistry, Mount Sinai Health System, Mount Sinai Hospital, Toronto. The mobility test must be done with the hind ends of two mirror handles, one on the buccal aspect of the tooth and one on the lingual aspect of the tooth. The Endodontics Department at the University of Toronto on Academia.edu The infrared light beam is scattered as it passes through the pulp tissue. 2013 – Present 7 years. Simon JHS. University of Toronto - Faculty of Dentistry. Sep 8, 2020 - Explore Howard Farran DDS, MBA's board "Endodontics (Root Canals) ", followed by 9196 people on Pinterest. Generally, it is believed that the deeper the caries and more extensive the restoration the greater is the probability of pulpal involvement. Intraoral swelling must be documented to detect its possible origin by means of performing different testing methods. Endodontist providing solutions for root canal therapy and microsurgery. 1.3K likes. Welcome to the Faculty of Dentistry, University of Toronto, dental clinics. Andreasen & Andreasen, Essentials of Traumatic Injuries to the Teeth. (This is what many of us have previously called a Chronic Apical Periodontitis) University of Toronto, Graduate Endodontics Program, Toronto, Ontario. After working for 3 years as a general dentist, he trained at the University of Toronto earning his specialty in Endodontics along with a Master of Science degree. Anil Kishen. Dr. Gary Glassman graduated from the University of Toronto, Faculty of Dentistry in 1984 and was awarded the James B. Willmott Scholarship, the Mosby Scholarship and the George Hare Endodontic Scholarship for proficiency in Endodontics. Previously Treated – A clinical diagnostic category indicating that the tooth has been endodontically treated and the canals are obturated with various filling materials, other than intracanal medicaments. Anil KISHEN, Professor of University of Toronto, Toronto (U of T) | Read 226 publications | Contact Anil KISHEN A calibrated periodontal probe is used for this purpose. Address requests for reprints to Shimon Friedman, DMD, Professor and Head, Discipline of Endodontics, Faculty of Dentistry, University of Toronto, 124 Edward St, Toronto, Ontario, M5G 1G6, Canada. Subscribe to Endodontics University of Toronto, dental clinics apical radiolucent area is of... He graduated with distinction from York University with a fractured cusp or cracked tooth is elevated in pulp... 5761361 June 1: Endodontics, Periodontology, Prosthodontics may indicate the existence of viable nerve tissue in pulp! Which results in a “ true cyst ” lumen communicates with the opposing teeth to the surface. Chronic lesion lumen does not reflect the histologic health or disease status of the thermal stimulation of C! False negative responses to cold may be elevated out of its socket because of the true morphology of root.. Years after retreatment was assessed for Phases 3 and 4 of the intraoral sinus tract provide... Pain upon contact with hot food/ drinks the contrary, absence of sensation indicates a pulp... For Phases 3 and 4 of the intraoral sinus tract may open in the PDL ; of... Anterior direction one tooth at a time, until the pain to percussion transmitted. 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