diagnotic charts

Eugene A. Pantera, Jr., DDS, MS Department of Periodontics and Endodontics

Clinical Diagnosis University at Buffalo

1

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.

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.

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.

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.

EPT Response is normal and not in extremes. Is

generally in the same range as control teeth.

Thermal Tests Usual, normal response, for duration of the

stimulus. Reaction may be severe, but BRIEF.

Percussion and Palpation Negative, no response.


2

Pulpal Diagnosis Endodontic Treatment IS Needed

CLINICAL CLASSIFICATION SIGNS AND SYMPTOMS

DIAGNOSTIC TEST RESULTS

Irreversible Pulpitis 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.

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. 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.

EPT Tooth may test within normal limits. Response may be markedly different from

control, rapid/delayed onset, persistent, and may be of severe intensity.

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.


3

Pulpal Diagnosis Endodontic Treatment IS Needed



Necrotic Pulp 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.

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. 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. Radiology May be normal. May be periapical lesions or lateral lesions. An enlarged PDL may also be present.

EPT No response. May have false positives. Thermal Test No response. Percussion Test May or may not be positive. Palpation May or may not be positive.


4

Periapical Diagnosis There MAY be Need for Endodontic Treatment PULPAL DIAGNOSIS IS REQUIRED FOR DEFINITIVE DETERMINATION



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. Etiology Irreversible pulpitis, traumatic injuries, periodontal disease, orthodontic forces maxillary sinusitis, pressure from periapical tumors, restoration in hyperocclusion.

Pulp Tests EPT and Thermal tests may be normal, or

similar to irreversible pulpitis or pulpal necrosis.

Percussion Moderate to severe pain. Palpation Moderate to severe pain. Radiology Usually thickening of PDL, also can have

periapical or lateral radiolucency, or normal.

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.


similar to irreversible pulpitis or pulpal necrosis.

Percussion Moderate to none. Palpation Moderate to none. May be swelling. Radiology Periapical or lateral radiolucency.


5

Periapical Diagnosis There IS a Need for Endodontic Treatment PULPAL DIAGNOSIS IS REQUIRED FOR DEFINITIVE DETERMINATION



Chronic Suppurative Apical Periodontitis 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.

Pain History of pain. Usually no pain present. Etiology Irreversible pulpitis, traumatic injuries, periodontal disease, orthodontic forces, restoration in hyperocclusion.


similar to irreversible pulpitis or pulpal necrosis. (Is this a lesion of endodontic origin?)

Percussion None to slight pain. 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. Etiology The result of coronal apical progression of pulpal

necrosis with resultant release of antigens into the periapical tissues.

Pulp Tests No response. Percussion Moderate to severe. Palpation Moderate to severe. Swelling probable. Radiology PDL thickening, periapical or lateral

radiolucency.

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