Eugene A. Pantera, Jr., DDS, MS Department of Periodontics and Endodontics
Clinical Diagnosis University at Buffalo
Pulpal Diagnosis Endodontic Treatment is NOT Needed CLINICAL CLASSIFICATION
SIGNS AND SYMPTOMS
DIAGNOSTIC TEST RESULTS
Normal A pulpal condition, usually called normal, in which the pulp responds to thermal and electrical tests in a manner similar to that of a corresponding control tooth.
Pain No history of pain. None to mild to moderate intensity Pain is non-spontaneous No pain with percussion Moderate to sharp response to thermal, sweet, or sour stimuli; response subsides when stimulus is removed.
EPT Response is normal and not in extremes. Is generally in the same range as control teeth.
Hypersensitive Dentin A pulpal condition, with no apparent histologic changes, in which the patient feels pain when the dentin is exposed to touch from a dental explorer, fingernail or tooth brush and to thermal or to other stimuli. However the pain disappears when the stimulus is removed. Reversible Pulpitis Syn: hyperemia, inflamed-reversible. A pulpal condition commonly induced by dental caries and operative procedures, in which the patient responds to thermal or osmotic stimuli, but the symptoms disappear when the etiology is eliminated.
Etiology Usually caries, defective restoration, restorative procedures, mechanical pulp exposures, tooth brush abrasion, tooth fracture, recent prophylaxis, or subgingival scaling and curettage. Radiology No radiographic evidence of pulp calcifications, internal resorption, or periapical changes.
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Thermal Tests Usual, normal response, for duration of the stimulus. Reaction may be severe, but BRIEF.
Percussion and Palpation Negative, no response.
Eugene A. Pantera, Jr., DDS, MS Department of Periodontics and Endodontics
Pulpal Diagnosis Endodontic Treatment IS Needed
CLINICAL CLASSIFICATION
SIGNS AND SYMPTOMS
DIAGNOSTIC TEST RESULTS
Irreversible Pulpitis
Pain May have acute or chronic symptoms. Sharp, exaggerated, painful response to thermal stimulus; pain lingers after stimulus is removed. Pain may be spontaneous; maybe past repeated episodes of pain, often continuous pain. Pain with mastication.
EPT Tooth may test within normal limits. Response may be markedly different from control, rapid/delayed onset, persistent, and may be of severe intensity.
Irreversible pulpitis without periapical pathosis A pulpal condition, usually caused by deep dental caries or restorations, in which spontaneous pain may occur or be precipitated by thermal or other stimuli. Radiographs show no periapical changes. The pain last for several minutes to hours.
Irreversible pulpitis with periapical pathosis A pulpal condition similar to above, but in which periapical or lateral radiographic changes are evident.
Etiology Deep caries and/or restorations, evidence of previous pulp cap. Exposed dentin (attrition, abrasion, and erosion). Traumatic injuries. Resorption (especially perforating). Orthodontic forces.
Radiology May be normal. Radiographic evidence may reveal normal pulp, calcifications, narrow pulp chamber, "calcified" canals, , or condensing osteitis. An enlarged PDL may also be present.
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Thermal Test A key factor in making a diagnosis. May be abnormal, rapid/delayed onset, greater intensity and longer duration. Percussion Test May or may not be positive. Palpation May or may not be positive.
Eugene A. Pantera, Jr., DDS, MS Department of Periodontics and Endodontics
Pulpal Diagnosis Endodontic Treatment IS Needed
CLINICAL CLASSIFICATION
SIGNS AND SYMPTOMS
DIAGNOSTIC TEST RESULTS
Necrotic Pulp
Pain May have acute or chronic symptoms. Pain may be spontaneous; maybe past repeated episodes of pain, often continuous, dull, throbbing, pain. Pain with mastication.
EPT No response. May have false positives.
Etiology Deep caries and/or restorations, evidence of previous pulp cap. Carious pulp exposures. Exposed dentin (attrition, abrasion, and erosion). Traumatic injuries. Resorption (especially perforating). Orthodontic forces.
Percussion Test May or may not be positive.
Necrotic pulp without periapical pathosis A pulpal condition in which there may or may not be spontaneous moderate to severe pain or pain elicited by various stimuli. Response to various testing modalities is usually absent. Radiographic changes are not evident.
Necrotic pulp with periapical pathosis A pulpal condition similar to above, except that in this category periapical or lateral lesions are evident in radiographs.
Radiology May be normal. May be periapical lesions or lateral lesions. An enlarged PDL may also be present.
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Thermal Test No response.
Palpation May or may not be positive.
Eugene A. Pantera, Jr., DDS, MS Department of Periodontics and Endodontics
Periapical Diagnosis There MAY be Need for Endodontic Treatment PULPAL DIAGNOSIS IS REQUIRED FOR DEFINITIVE DETERMINATION CLINICAL CLASSIFICATION
SIGNS AND SYMPTOMS
DIAGNOSTIC TEST RESULTS
Acute Apical Periodontitis
Pain History of pulpal pain. Moderate to severe intensity that may be intermittent. Periapical pain usually requires stimulus (eg mastication). Pain can be sharp. Aggravating factors are usually present.
Pulp Tests EPT and Thermal tests may be normal, or similar to irreversible pulpitis or pulpal necrosis.
Etiology Irreversible pulpitis, traumatic injuries, periodontal disease, orthodontic forces maxillary sinusitis, pressure from periapical tumors, restoration in hyperocclusion. Chronic Apical Periodontitis A periapical condition characterized by none to slight pain on mastication but may present itself with varying degrees of apical swelling. Radiographs reveal periapical or lateral radiolucencies.
Pain History of pain. Slight intensity to no pain. Pain may be absent or constant. Periapical pain can be spontaneous. Pain is dull throbbing. Pain can occur with mastication. Etiology Same as for Acute apical periodontitis.
Percussion Moderate to severe pain. Palpation Moderate to severe pain. Radiology Usually thickening of PDL, also can have periapical or lateral radiolucency, or normal. Pulp Tests EPT and Thermal tests may be normal, or similar to irreversible pulpitis or pulpal necrosis. Percussion Moderate to none. Palpation Moderate to none. May be swelling. Radiology Periapical or lateral radiolucency.
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Eugene A. Pantera, Jr., DDS, MS Department of Periodontics and Endodontics
Periapical Diagnosis There IS a Need for Endodontic Treatment PULPAL DIAGNOSIS IS REQUIRED FOR DEFINITIVE DETERMINATION CLINICAL CLASSIFICATION
SIGNS AND SYMPTOMS
DIAGNOSTIC TEST RESULTS
Chronic Suppurative Apical Periodontitis
Pain History of pain. Usually no pain present.
Pulp Tests EPT and Thermal tests may be normal, or similar to irreversible pulpitis or pulpal necrosis. (Is this a lesion of endodontic origin?)
Etiology Irreversible pulpitis, traumatic injuries, periodontal disease, orthodontic forces, restoration in hyperocclusion.
Percussion None to slight pain.
A periapical condition characterized by non pain on mastication. A draining sinus tract or other evidence of suppuration is evident. Radiographs reveal periapical or lateral radiolucencies.
Palpation Slightly tender. Radiology Periapical or lateral radiolucency. Visual Sinus tract present.
Acute Alveolar Abscess Syn: Acute apical abscess An acute alveolar abscess is a severe clinical manifestation of periapical infectious disease, characterized by severe pain and swelling.
Pain History of pain. Severe intensity. Constant and spontaneous pain. Pain is pulsing and throbbing. Pain can occur with mastication.
Pulp Tests No response. Percussion Moderate to severe. Palpation Moderate to severe. Swelling probable.
Etiology The result of coronal apical progression of pulpal necrosis with resultant release of antigens into the periapical tissues.
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Radiology PDL thickening, periapical or lateral radiolucency.
