Dr. Mario Castro – Private Practice for Endodontics and Microscopic Dentistry in Vienna
Historically, there have been a variety of diagnostic classification systems in endodonticsthat were used to describe endodontic conditions. Unfortunately, many of these were based on histopathological findings rather than clinical observations, often leading to confusion, misleading terminology, and incorrect diagnoses. One of the main reasons for establishing a pulp and periapical diagnosis is to determine the necessary clinical treatment. An incorrect assessment can, for example, lead to inappropriate treatment, including the performance of a unnecessary endodontic treatment., the omission of necessary treatment, or the implementation of another treatment when endodontic therapy is actually required. Another important reason for establishing a universal classification system is to provide a basis for communication between educators, practitioners, students, and researchers. A simple and practical system that uses the terminology of clinical findings is essential and helps practitioners understand the progressive characteristics of diseases in the pulp and periapical areas by providing the appropriate treatment for each condition.
In 2008, the American Association of Endodontists (AAE) organized a consensus conference to standardize the diagnostic terminology used in endodontics. The goal was to develop general recommendations for endodontic diagnoses; establish a standardized definition of the fundamental diagnostic terms to be accepted by endodontists, third-party providers, general dentists, other dental specialists, and students; eliminate ambiguities in the review and evaluation of outcomes; and, finally, establish radiographic, objective test, and clinical criteria to confirm the diagnostic terms developed at the conference.
Both the AAE and the American Board of Endodontics have accepted these terms and recommend their use in all dental and health-related fields. Each of the following diagnostic terms is defined by its typical clinical and radiographic characteristics, along with case examples where helpful. In all cases, practitioners should keep in mind that diseases of the pulp and periapical area are dynamic and progressive, meaning that signs and symptoms can vary depending on the stage of the disease and the patient’s condition. This also highlights the limitations of current pulp testing methods, as well as clinical and radiographic examination techniques.
To ensure appropriate treatment, a endodontic diagnosis should include an analysis of the pulp and periapical area for each affected tooth.
Examination and Diagnostic Procedures in Endodontics
The endodontic diagnosis is similar to putting together a puzzle: a diagnosis cannot be made from a single, isolated piece of information. The practitioner must systematically gather all necessary information to create a "probable" diagnosis. When compiling the medical and dental history, the practitioner should mentally form a preliminary but logical diagnosis, especially if a primary complaint is present. Clinical and radiographic examinations, combined with a thorough periodontal assessment and clinical tests (pulp and periapical tests), are used to confirm the preliminary diagnosis. In some cases, clinical and radiographic examinations are ambiguous or provide conflicting results, making it impossible to establish definitive diagnoses regarding the pulp and periapical area. It is also important to recognize that no treatment should be performed without a diagnosis, and the patient should either wait for a reassessment of their condition or be referred to an endodontist.
Examination Techniques Required for an Endodontic Diagnosis
1. Medical/Dental History: past/current treatments, medications.
2. Main complaint (if applicable)): duration of symptoms, duration of pain, location, progression, triggers, relief, pain radiation, medications.
3. Clinical Examination: facial symmetry, sinus tract, soft tissue, periodontal condition (probing, mobility), caries, restorations (leakage, new?).
4. Clinical Tests:
– Pulp Tests: cold, heat, electric.
– Periapical Tests: percussion, palpation, biting.
5. Radiographic Analysis: new periapical images (at least 2), bitewings, cone-beam computed tomography (CBCT).
6. Additional Tests: transillumination, selective anesthesia.
Diagnostic Terminology Recognized by the American Association of Endodontists and the American Board of Endodontics
Pulp Diagnoses
– Normal Pulp: A clinical diagnosis in which the pulp is free of symptoms and responds normally to pulp tests. The pulp may not be histologically normal, but a "clinically" normal pulp exhibits a mild or transient response to cold/heat tests that does not last more than one or two seconds after the stimulus is removed. A probable diagnosis cannot be made without comparing the affected tooth to adjacent and opposing teeth. It is recommended to test the adjacent and opposing teeth first so the patient can become familiar with the sensation of a normal cold response.
– Reversible PulpitisBased on subjective and objective findings indicating that the inflammation should subside and the pulp can return to its normal state with appropriate treatment of the underlying cause. Discomfort occurs when a stimulus such as "cold" or "sweetness" is applied and disappears within seconds after the stimulus is removed. Typical causes include exposed dentin (dentin hypersensitivity), caries, or deep restorations. Radiographs show no significant differences in the periapical area of the potentially affected tooth, and the pain experienced is not spontaneous. With the correct approach to treating the underlying cause (e.g., removal of caries and restoration; covering exposed dentin), the tooth must be further evaluated to determine if the "reversible pulpitis" resolves into a normal condition. Although dentin hypersensitivity itself is not an inflammatory process, all its symptoms closely resemble those of reversible pulpitis.
– Symptomatic Irreversible Pulpitis: Based on subjective and objective findings indicating that the inflamed vital pulp cannot heal and requires root canal treatment is recommended. Symptoms may include intense pain caused by thermal stimuli. Other signs include lingering pain (usually lasting 30 seconds or longer after the stimulus is removed), spontaneous or non-localized pain (pain that manifests in a location other than the affected area). In some cases, the pain worsens with changes in position, such as lying down or bending forward, and over-the-counter pain relievers are often ineffective. Common causes include deep caries, extensive restorations, or fractures that expose the pulp tissue. Assessing the tooth's condition, along with cold and heat tests, are the primary options for evaluating the pulp's status in these cases.
– Asymptomatic Irreversible Pulpitis: Clinical diagnosis based on subjective and objective findings indicating that the inflamed vital pulp cannot heal and requires a root canal treatment is recommended. These cases show no clinical symptoms and respond normally to thermal tests, although they may have experienced trauma or have deep caries that will likely expose the pulp upon removal.
– Pulp Necrosis: Clinical diagnosis category indicating the death of the dental pulp and the need for a root canal treatment treatment. The pulp does not respond to pulp tests and is asymptomatic. Pulp necrosis itself does not cause apical periodontitis (pain upon percussion or radiographic evidence of bone loss) unless the canal is infected.
– Previously Treated (Vorher behandelt: A clinical diagnosis category indicating that the tooth has been endodontically treated and the canals have been filled with various filling materials and intracanal medications. The tooth typically does not respond to cold, heat, or electric pulp tests.
– Previously Initiated Therapy (Früher eingeleitete Therapie): Clinical diagnosis category indicating that the tooth has been partially endodontically treated, such as through a pulpotomy or pulpectomy. Depending on the phase of therapy, the tooth may or may not respond to pulp tests.
Apical Diagnoses
– Normal Apical Tissue: Does not respond sensitively to percussion or palpation tests. Radiographically, the "lamina dura" surrounding the root is intact, and the periodontal space is uniform. As with pulp tests, comparative percussion and palpation tests should always be performed.
– Symptomatic Apical Periodontitis: Typically indicates inflammation of the apical periodontium and causes clinical symptoms such as a painful response to biting and/or percussion or palpation. A periapical radiolucent area may or may not be present, depending on the disease state and the thickness of the surrounding bone. Symptomatic apical periodontitis can be caused by persistent pulpitis (symptomatic irreversible pulpitis) and represents the next stage of the disease, leading to pulp necrosis and chronic apical periodontitis.
– Asymptomatic Apical Periodontitis: A clinical diagnosis typically caused by pulp necrosis, leading to apical inflammation but without clinical symptoms. Apical radiolucent lesions, such as granulomas, cysts, or scars, are usually observed radiographically. Chronic apical radiolucent lesions are asymptomatic because the bone is resorbed, and there is no pressure to cause discomfort.
– Acute Apical Abscess: A clinical diagnosis of a purulent inflammation of the apical periodontium that causes spontaneous pain, tenderness to pressure, and sensitivity to percussion and/or palpation. The condition can develop rapidly, and the patient may experience fever, malaise, and lymphadenopathy. The tooth may or may not exhibit an apical radiolucent lesion. Swelling may be confined to the intraosseous area, forming a tumefaction (localized abscess), or it may spread to mucosal or dermal areas, causing cellulitis (diffuse abscess).
– Chronic Apical Abscess: A clinical diagnosis of inflammation characterized by pus discharge through a sinus tract associated with pulp necrosis. It is usually asymptomatic because the sinus tract drains, preventing pressure buildup. Radiographically, it may be associated with an apical radiolucent lesion.
