Pulpal Diagnosis and Inflammation

Pulpal Diagnosis Categories

• Normal Pulp
• Reversible Pulpitis
• Asymptomatic Irreversible Pulpitis
• Symptomatic Irreversible Pulpitis
• Pulp Necrosis
• Previously Initiated
• Previously Treated

Pulpal Inflammation

• Inflammation begins and progresses, either reversibly or irreversibly.

Pulpal Degeneration

• Progresses from normal pulp, to reversible pulpitis, which can become either symptomatic or asymptomatic irreversible pulpitis, and can eventually result to pulp necrosis

Normal Pulp

• Defines a clinical diagnostic category where the pulp is symptom-free and responds normally to pulp testing.

Reversible Pulpitis

• Clinical diagnosis based on subjective and objective findings, inflammation should resolve, and the pulp should return to normal.
• Mild symptoms, such as thermal stimulus, may be reported.
• Etiology can be caused by caries, exposed dentin, recent dental treatment, or defective restorations.

Asymptomatic Irreversible Pulpitis

• Clinical diagnosis where the vital inflamed pulp is incapable of healing.
• Patients typically have a history of trauma or deep caries, likely resulting in exposure after removal.
• Usually responds normally to thermal testing.
• Usually has a history of trauma or deep caries that likely results in exposure following removal.

Symptomatic Irreversible Pulpitis

• Clinical diagnosis involving a vital inflamed pulp incapable of healing.
• Characteristics include sharp, lingering thermal pain (>30 seconds after removal), spontaneous pain, referred pain, and pain waking the patient from sleep.
• Over-the-counter analgesics are typically ineffective.

Pulp Necrosis

• Clinical diagnostic category indicating the death of the dental pulp.
• The pulp is usually nonresponsive to pulp testing and asymptomatic.
• Teeth may be nonresponsive to pulp testing due to calcification, recent trauma history, or if the tooth simply is not responding, but this does not necessarily indicate necrosis.

Previously Initiated Therapy

• Clinical diagnostic category indicating that the tooth has been previously treated by partial endodontic therapy, like pulpotomy or pulpectomy.

Previously Treated

• Clinical diagnostic category indicating that the tooth has been endodontically treated.
• The canals are obturated with various filling materials other than intracanal medicaments.

Periapical Diagnosis

• Pulp necrosis and bacteria must be present to cause periapical degeneration.

Periapical Diagnosis Categories

• Normal Apical Tissues
• Symptomatic Apical Periodontitis
• Asymptomatic Apical Periodontitis
• Acute Apical Abscess
• Chronic Apical Abscess
• Condensing Osteitis

Normal Apical Tissues

• Clinical tests show normal response, without sensitivity to percussion or palpation.
• Radiographs should show an intact lamina dura surrounding the root and a uniform periodontal ligament space.
• Comparative testing for percussion and palpation should begin with normal teeth as a baseline.

Symptomatic Apical Periodontitis

• Definition: Inflammation typically affects the apical periodontium, resulting in clinical symptoms.
• Clinical exam: There is usually a painful response to biting and/or percussion or palpation.
• Changes can be present depending on the progression of the disease.

Asymptomatic Apical Periodontitis

• Characterized by inflammation and destruction of the apical periodontium of pulpal origin.
• Clinical exam: There is a normal response, with no symptoms to percussion/palpation.
• Radiographic exam: Presents as an apical radiolucency.
• Differentiating from anatomic features or non-endodontic pathology needs to be done with pulpal testing.

Acute Apical Abscess

• Inflammatory reaction to pulpal infection and necrosis, characterized by rapid onset, spontaneous pain, extreme tenderness to pressure, pus formation, and swelling of tissues.
• Patients may experience malaise, fever, and lymphadenopathy.
• Radiographic changes may or may not be noted.

Chronic Apical Abscess

• An inflammatory reaction to pulpal infection and necrosis is characterized by gradual onset, little to no discomfort, and intermittent pus discharge through a sinus tract.
• Radiographic exam generally shows osseous destruction, such as radiolucency.
• Source of a draining sinus tract is identified by putting a gutta percha cone through the stoma until it stops and taking a radiograph.

Sinus Tract vs. Fistula

• Fistula: abnormal communication pathway between 2 internal organs.
• Sinus Tract: pathway from an enclosed infected area to an epithelial surface.
• Sinus tract opening or stoma is typically intraoral or extraoral and allows pus discharge, and typically disappears when causative factor by endodontic treatment.

Condensing Osteitis

• Diffuse radiopaque lesion shown as a localized bony reaction to low-grade inflammatory stimulus, usually seen at the apex of the tooth.
• Radiographic diagnosis that can be specified as an adjunct to another periapical diagnoses, such as symptomatic apical periodontitis with condensing osteitis.